Corrected TIMI Frame Count Research Articles

Relationship Between Plasma Total Homocysteine Levels and Mean Corrected TIMI Frame Count in Patients with Acute Myocardial Infarction.

ObjectiveTo explore the relationship between the plasma total homocysteine (tHcy) levels and slow coronary flow (SCF) measured by mean corrected TIMI frame count (CTFC) in patients with acute myocardial infarction (AMI).MethodsNinety-one patients with primary myocardial infarction were enrolled in this study. The quantitative measurement of coronary blood flow was performed using the mean CTFC method. Plasma tHcy levels were determined using enzymatic assay from venous blood samples. Multivariable linear regression models indicated were used to estimate the effect size (β) of plasma tHcy levels on mean CTFC levels.ResultsCompared with patients with the mean CTFC ≤23.61 frames per second (FPS) group, there were increased plasma tHcy levels in patients of the second, third and highest mean CTFC quartiles (P < 0.001). Linear regression models indicated that plasma tHcy levels were positively associated with mean CTFC levels (adjusted-β per SD increase: 1.96, 95% CI 1.20 to 2.73, P < 0.001). Compared to the tHcy ≤12.30 μmol/L group, the third and highest tHcy-quartile groups had higher mean CTFC levels (adjusted-β: 2.52, 95% CI 0.39 to 4.65, P = 0.023; adjusted-β: 5.07, 95% CI 2.98 to 7.16, P < 0.001, respectively; P for trend <0.001). Moreover, this positive relationship was modified by diabetes mellitus (P-value for interaction was 0.046).ConclusionWe found a positive relationship between plasma tHcy levels and mean CTFC levels in patients with AMI. Moreover, diabetes mellitus played an interactive role in this positive association between the plasma tHcy levels and mean CTFC levels.

The efficacy and safety of the short-term combination therapy with ticagrelor and PPIs or H2RA in patients with acute STEMI who underwent emergency PCI.

Combination therapy with platelet inhibitors and acid‐suppressive agents is recommended for patients with acute ST‐segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI), but there remains a paucity of data to evaluate both the efficacy and safety of these combinations. In this prospective study, a total of 170 patients with acute STEMI who underwent PCI were divided into four groups: pantoprazole + ticagrelor, omeprazole + ticagrelor, ranitidine + ticagrelor, and ticagrelor only. The risk of PCI, antithrombotic efficacy, cardiac function, and main end points were evaluated and compared. No significant differences were found in infarction‐related artery perfusion indexes (thrombolysis in myocardial infarction [TIMI], corrected TIMI frame count), the incidence of stent thrombosis after PCI, platelet indicators (platelet count, mean platelet volume, and platelet distribution width), platelet activation (P‐selectin and glycoprotein IIb/IIIa levels), platelet aggregation (thrombelastography indicators, such as ADP% and MAADP), myocardial necrosis biomarker (creatine kinase isoenzyme‐MB and cardiac troponin I) levels, brain natriuretic peptide levels, the incidence of ischemic end point events, and the incidence of other tissue and organ bleeding events among the four groups. The incidence of gastrointestinal (GI) bleeding events in the proton pump‐inhibitor (PPI) group was significantly lower than that in the control group, whereas in the H2 receptor antagonist (H2RA) group it was not significantly different from the control group. The short‐term combination therapy with ticagrelor and PPIs or H2RA is safe and effective in patients with acute STEMI after PCI. In addition, the PPIs combined with ticagrelor could reduce the incidence of GI bleeding events without increasing the incidence of ischemic events.

Efficacy of Distal Intracoronary Epinephrine and Glycoprotein IIb/IIIa Inhibitors in the Treatment of No-reflow during Percutaneous

Background: No-reflow is considered a major percutaneous coronary intervention complication, especially in primary PCI. A variety of medications have been studied for no-reflow treatment, including intracoronary nitrates, verapamil, adenosine, glycoprotein IIb/IIIa inhibitors, and epinephrine. Glycoprotein IIb/IIIa inhibitors and epinephrine are the two most promising agents for the treatment of no-reflow. Aim of work: evaluating epinephrine and glycoprotein IIb/IIIa inhibitors efficacy in treating no-reflow through local distal intracoronary injection in comparison to traditional intracoronary administration in the guiding catheter. Subjects and methods: 30 patients undergoing PCI complicated by no-reflow phenomenon. Patients were randomized to either group I where they were treated by local distal intracoronary injection of GP IIb/IIIa inhibitor and epinephrine or to group II where they received the same medications via the traditional intracoronary injection. Primary outcomes were TIMI flow, corrected TIMI frame count and TMPG, and major adverse cardiac events within 48 hours was the secondary outcome. Results: Group I had significantly superior angiographic outcomes than group II. As regards TIMI II-III flow, 86.7% of patients achieved it in versus 53.3% in group II, CTFC was 8.2versus 9.9, and in group I, 80% of patients achieved TMPG II-III, compared to 46.7 % in group II. MACE was insignificantly different between both groups. Diabetes mellitus was found to be the only predictor to be negatively associated with TIMI flow. Conclusion: Distal coronary artery local injection of a combination of GP IIb/IIIa inhibitors and epinephrine achieved superior angiographic outcomes in the treatment of refractory no-reflow in comparison with traditional intracoronary administration of the same medications.

Improved Cardiac Function and Attenuated Inflammatory Response by Additional Administration of Tirofiban during PCI for ST-Segment Elevation Myocardial Infarction Patients.

ST-segment elevation myocardial infarction (STEMI) is one of the acute coronary syndromes, and it is the main cause of cardiac death worldwide. The purpose of this study was to investigate whether tirofiban improves cardiac function and attenuates inflammatory response in STEMI patients undergoing percutaneous coronary intervention (PCI). From May 2016 to May 2019, a total of 124 patients who admitted into our hospital due to STEMI fulfilled inclusion and exclusion criteria and were randomly assigned to PCI + tirofiban and PCI groups, 62 cases per groups. Intravenous administration of 10 μg kg−1 min−1 tirofiban was performed 30 min prior to PCI. During PCI, tirofiban infusion through a micropump with 0.15 μg kg−1 min−1 lasted for 48 h. It was found that the PCI + tirofiban group was significantly different from the PCI group in total corrected TIMI frame count (CTFC) after PCI (15.88 ± 5.11 vs. 22.47 ± 6.26, P < 0.001). At day 7 and day 30 post-PCI, a significant time-dependent decrease in the levels of brain natriuretic peptide (BNP), cardiac troponin I (cTnI), and creatine kinase isoenzyme (CK-MB) in both groups was observed after PCI (P < 0.001). More importantly, the patients in the PCI + tirofiban group had much lower levels of BNP, cTnI, and CK-MB compared with those in the PCI group at days 7 and 30 post-PCI (P < 0.001). At day 7 following PCI, the left ventricular ejection fraction (LVEF) was statistically higher in the PCI + tirofiban group than in the PCI group (P < 0.05). At day 30 post-PCI, increased LVEF concomitant with reduced left ventricular end diastolic diameter (LVEDD) and left ventricular end systolic diameter (LVESD) was observed in the PCI + tirofiban group compared with the PCI group. At day 7 and day 30 post-PCI, both groups displayed a time-dependent decline in the levels of C reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and procalcitonin (PCT) after PCI (P < 0.05). Additionally, the patients in the PCI + tirofiban group had lower levels of CRP, TNF-α, IL-6, and PCT compared with those in the PCI group at days 7 and 30 post-PCI (P < 0.05). All patients in the PCI + tirofiban and PCI groups were followed up for 12 months by outpatient or telephone after discharge. There were fewer patients with LVEF < 50% in the PCI + tirofiban group than the PCI group (P=0.044). Furthermore, it was found that the incidence rate of major adverse cardiovascular events (MACEs) in the PCI + tirofiban group was evidently lower than that in the PCI group (12.90% vs. 29.03%, P=0.028). Taken together, our data suggest that additional administration of tirofiban could improve cardiac function and attenuate inflammatory response in STEMI patients undergoing PCI, which is worthy of promotion in clinic.

Angiographic profiles in patients of persistent non-valvular atrial fibrillation from a tertiary care center in north india

Abstract Funding Acknowledgements Type of funding sources: None. Background The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established. Atrial ischemia due to obstructive CAD has been identified as one of the key risk factors, leading to AF. However, sufficient evidence exists as to the presence of myocardial ischemia on stress imaging, even without the presence of obstructive CAD in AF patients. Slow flow and coronary tortuosity on angiogram can lead to downstream myocardial ischemia independent of CAD. Purpose We aimed to delineate the angiographic profiles in AF patients with attention to slow flow and tortuosity leading to ischemia in those without obstructive CAD. Methods The study was a nonrandomised, prospective, single-centre observational study of consecutive patients of persistent non valvular AF. Symptomatic patients despite optimal medical therapy (OMT) for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with known CAD or prior history of myocardial infarction were excluded. Further angiographic analysis was done in those without obstructive CAD to determine incidence of slow flow (&amp;gt;27 corrected TIMI frame count) and tortuosity (presence of ≥3 fixed bends in an epicardial artery). Results A total of 70 patients were recruited and followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49). Hypertension (74%) was the commonest comorbidity followed by obesity (35%) and diabetes (30%). At CAG, 32/70 (45%) had obstructive CAD, 17/70 (24%) had non obstructive (&amp;lt;50-70% stenosis) CAD and 21/70 (30%) had normal coronaries without atherosclerosis. Amongst patients without obstructive CAD (n = 38) slow flow was seen in 16/38 (42%) and coronary tortuosity in 11/38 (29%) patients. There ware no differences in terms of death, HF and FVR hospitalisations or stroke at follow up between the obstructive CAD vs no obstructive CAD. However in patients without obstructive CAD, hospitalisations for FVR was significantly increased in those having slow flow on CAG, 9/12 (75%) vs 7/26 (27%) in those without slow flow (p value = 0.005). The mean TIMI frame count was also significantly higher in those with FVR hospitalisations 35.3 ± 11 vs 25.8 ± 8.9 (p value = 0.005). TIMI frame count &amp;gt;31 had a sensitivity of 83% and a specificity of 69% for predicting hospitalisations for FVR on ROC curve(AUC = 0.71). Conclusions CAD is closely related to AF and majority (70%) of our patients had evidence of atherosclerotic CAD on CAG in our study. A large proportion of patients with no evidence of obstructive CAD on CAG had slow flow or coronary tortuosity. Significantly increased hospitalisation for FVR seen in the slow flow group shows its significance and may lead to newer treatment modalities in future. Further larger studies looking at these aspects on CAG may give further insight as to the nature and prognosis of these entities.

Thrombus aspiration during primary percutaneous coronary intervention improved outcome in patients with STEMI and a large thrombus burden.

BackgroundThe benefit of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) to patients with ST-segment elevation myocardial infarction (STEMI) remains controversial. This study aimed to assess TA's impact on the outcome and prognosis for patients with STEMI and a large thrombus burden during PPCI.MethodsThis retrospective study evaluated consecutive patients with STEMI and a large thrombus burden (thrombolysis in myocardial infraction [TIMI] thrombus grade ≥4) who underwent conventional PPCI (n = 126) or PPCI + TA (n = 208) between February 2017 and January 2019. The procedure outcome and clinical prognosis were compared.ResultsPostprocedural vessel diameter was larger, and corrected TIMI frame count (cTFC) was lower in the PPCI + TA compared with the PPCI group. The proportion of postprocedural TIMI 3 flow was 83.3% in the PPC group and 94.2% in the PPCI+TA group. During the 12-month follow-up, no significant differences existed in the incidence of cardiac death, reinfarction, stent thrombosis, target vessel revascularization, or stroke.ConclusionApplication of TA in patients with STEMI and a large thrombus burden during PPCI may improve the procedural outcome, but it showed no benefit on the clinical prognosis in the 12-month follow-up. Longer follow-up studies are needed to confirm TA's clinical implications in patients with STEMI.

Myocardial protective effect of intracoronary administration of nicorandil and alprostadil via targeted perfusion microcatheter in patients undergoing elective percutaneous coronary intervention: A randomized controlled trial.

Background:The aim of the study was to evaluate the efficacy of nicorandil and alprostadil on myocardial protection in patients undergoing elective percutaneous coronary intervention (PCI).Methods:In this prospective, single-blinded, randomized controlled study, 90 consecutive patients scheduled for elective PCI for de novo coronary lesions were assigned to the nicorandil, alprostadil, and nitroglycerin groups in a 1:1:1 ratio. Drugs were administered intracoronary via a targeted perfusion microcatheter. The primary endpoint was the thrombolysis in myocardial infarction (TIMI) myocardial perfusion frame count (TMPFC). Additionally, the corrected TIMI frame count (cTFC), TIMI myocardial perfusion grade (TMPG), and incidence of periprocedural myocardial injury (PMI) were assessed.Results:Both nicorandil and alprostadil were significantly effective in reducing TMPFC (114.6 ± 33.7 vs 93.4 ± 30.9, P = .016; 114.3 ± 34.3 vs 94.7 ± 33.3, P = .029, respectively). Similar findings were observed in the improvement of cTFC (20.3 ± 10.5 vs 13.5 ± 5.0, P = .003; 20.2 ± 7.4 vs 15.2 ± 5.2, P = .003, respectively) and percentage of TMPG 3 (100% vs 82.8%, P = .052; 83.3% vs 96.7%, P = .196, respectively); whereas, nitroglycerin produced a limited effect on TMPFC (114.4 ± 30.9 vs 112.1 ± 31.9, P = .739), cTFC (19.4 ± 7.2 vs 19.3 ± 7.2, P = .936), and percentage of TMPG 3 (86.7% vs 86.7%, P = 1.000). No significant difference was found in the incidence of PMI (16.7% vs 16.0% vs 27.6%, P = .537), though it was comparatively lower in the nicorandil and alprostadil groups. Furthermore, the intracoronary administration of nicorandil and alprostadil had a mild effect on blood pressure and heart rate.Conclusions:The intracoronary administration of nicorandil and alprostadil via a targeted perfusion microcatheter was more effective in improving myocardial perfusion in patients undergoing elective PCI than nitroglycerin.

A preliminary study of MMP-9 and sCD40L in patients with coronary slow flow.

To explore the relationship between coronary slow flow (CSF) and both matrix metalloproteinase-9 (MMP-9) and soluble cluster of differentiation 40 ligand (sCD40L). Between July 2016 and September 2019, 80 patients suspected of having coronary heart disease due to chest tightness or other symptoms of chest pain and discomfort were admitted to Nanjing Jiangbei People's Hospital and, following a coronary angiography, were diagnosed as having CSF. These patients were assigned to the coronary slow flow phenomenon (CSFP) group. The control group, or normal coronary flow (NCF) group, consisted of 80 patients with normal coronary angiography results. Following group assignment, enzyme-linked immunosorbent assays (ELISAs) were used to measure and compare the serum levels of sCD40L and MMP-9 between the two groups. Serum levels of sCD40L and MMP-9 in the CSFP group were significantly higher than those in the NCF group (PP<0.05). Additionally, serum levels of adhesion molecules and C-reactive protein (CRP) in the CSFP group were significantly higher than those in NCF group (P<0.05). There was a positive correlation observed between sCD40L levels and adhesion molecule levels in the CSFP group, however, there was no such correlation observed in the NCF group. The CSFP group also had a significantly higher corrected TIMI frame count (CTFC) compared with the NCF group (PP<0.05). Serum MMP-9 levels were higher in patients with CSF, and MMP-9 levels were positively correlated with CTFC. This suggests that chronic inflammation may play a role in CSF pathogenesis and that atherosclerotic plaques may be present in the coronary arteries of CSF patients. Additionally, serum levels of sCD40L, adhesion molecules, and CRP were higher in CSF patients, and CRP levels were positively correlated with CTFC. Adhesion molecule expression is promoted by sCD40L. Increased levels of sCD40L may therefore promote the development of CSF.

Corrigendum to “Evaluation of the Correlation between Serum Concentrations of Asymmetric Dimethylarginine and Corrected TIMI Frame Count in Patients with Slow Coronary Flow”

[This corrects the article DOI: 10.1155/2020/4592190.].

Intracoronary nitroglycerin injection through a homemade side-hole ballon for coronary slow/no-reflow phenomenon prevention

Abstract Objective The evaluate nitroglycerin-injection during the homemade side-hole ballon into the proximal segment of the target lesion by TIMI blood flow and the corrected TIMI frame count (CTFC) during primary PCI for patients with ST-segment elevation myocardial infarction (STEMI). Methods All patients were diagnosed with STEMI. A dual antiplatelet therapy was given; patients were able to receive pPCI. The basic TIMI blood flow and CTFC were recorded after angiography and randomized according to the random number table by group A (n=61, early nitroglycerin injection via side-hole ballon) andgroup B (n=59, Traditional protocol PCI). Side-hole ballon was made by the ballon that passed the target lesion and puncture it with holes with needle. The TIMI blood flow and CTFC status immediately after the pPCI and the related events during the hospitalization and 6 months discharged. Results There were no significant differences between the baseline and laboratory parameters of the two groups (P&amp;gt;0.05). Also no differences in TIMI blood flow and CTFC frame before the target vessel was opened (P&amp;gt;0.05), Further no difference in number of implanted stents, stent length and diameter. The immediate effect after pPCI showed, the early nitroglycerin injection via side-hole ballon have effect on the TIMI blood flow (P=0.027), the CTFC (P=0.007) and the proportion of slow/no-reflow (6.56% vs. 22.03%, P=0.015). There was no difference in the incidence of MACE between two groups during hospitalization and 30 days follow-up. The incidence of MACE at 6 months follow-up was significantly lower in group A (1.63% vs. 10.17%, P=0.046). Conclusion In pPCI process, the early upstream nitroglycerin injection via homemade side-hole ballon can significantly reduce the incidence of slow/no-reflow after pPCI while the guidewire/balloon passes through the lesion. After pretreatment by this manner, the patient's 6-month MACE rate can be significantly improved. Figure 1 Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The basic research project of Anhui Medical University

Coronary blood flow in myocardial infarction with nonobstructive coronary arteries

Abstract Background Myocardial infarction (MI) is mainly caused by atherosclerotic plaque thrombosis but several registries show that in 1–13% of cases MI occurs in the absence of obstructive coronary artery disease (MINOCA) utilizing the conventional cut-off of &amp;lt;50% stenosis. MINOCA is generally related to coronary arteries abnormalities (epicardial or microvascular dysfunction – MINOCA-co). However, non-coronary conditions may underlie MINOCA as a consequence of supply-demand mismatch (MINOCA-nco). The TIMI flow gradient (TFG) and the corrected TIMI frame count (CTFC) are established methods able to respectively provide a qualitative and semiquantitative estimation of epicardial blood flow at rest. No studies have yet evaluated these indices in patients with MINOCA. Purpose To evaluate the clinical characteristics of patients with MINOCA and the angiographic indices in MINOCA-co versus MINOCA-nco. Methods Among all consecutive patients undergoing coronary angiogram at our Centre for MI based on the 4th Definition of Myocardial Infarction, the ones showing &amp;lt;50% coronary artery stenosis were retrospectively analyzed; patients with previous coronary stenting were excluded from the study. According to the presence or absence of pre-specified criteria of supply-demand mismatch (SAP &amp;gt;180 mmHg, DAP &amp;gt;110 mmHg, HR &amp;gt;110 bpm, Hb &amp;lt;6 gr/dl, SatO2 &amp;lt;91% or P/F ratio &amp;lt;300), the study cohort was divided into MINOCA-nco and MINOCA-co, respectively. We defined as slow flow phenomenon a TFG &amp;lt; = 2 and/or a CTFC &amp;gt;40 for the left anterior descending artery, &amp;gt;27 for the right coronary artery and &amp;gt;24 for the left circumflex. Results 453 patients were retrospectively evaluated and 112 (24.7%) met the inclusion criteria. Mean age was 68±13.2 years and 41 (36.6%) were males. MINOCA-co was the more prevalent entity accounting for 73 (65.2%) patients while 39 (34.8%) were MINOCA-nco. The two subgroups presented similar baseline characteristics with regards to gender and classic cardiovascular risk factors including hypertension, hypercholesterolemia, diabetes and smoking habit. Peripheral vasculopathy was more prevalent in MINOCA-nco patients (MINOCA-nco=15.4% vs. MINOCAco= 4.2%; p=0.04). Regarding the angiographic indices, there was no statistically significant difference in TFG between subgroups; conversely, the number of patients with a slow flow phenomenon as defined by CTFC was significantly higher in the MINOCA-nco group (MINOCAnco= 25.7% vs. MINOCA-co=9.8%; p=0.039). Conclusions Our data suggest that among patients with MINOCA clinical characteristics were not useful in differentiating between the two disease entities (MINOCA-nco vs. MINOCA-co). However, MINOCA-nco patients had higher coronary flow impairment as evaluated by CTFC. The pathophysiological reason is still not clear; we hypothesized that, in this clinical setting, an increased heart rate, systemic arterial pressure or low oxygen supply might worsen unbalanced coronary perfusion. Funding Acknowledgement Type of funding source: None

Intracoronary Versus Intravenous Administration of Eptifibatide During Percutaneous Coronary Intervention in Patients With Acute Coronary Syndromes

Platelet activation and aggregation play a major role in thrombosis formation of coronary arteries in patients with Acute Coronary Syndrome (ACS) and is responsible for most ischemic complications during PCI. There is little information on the benefits and side effects of intracoronary and intravenous injection of Eptifibatide, a potent antiplatelet agent; therefore, this study was performed with the aim to compare coronary blood flow velocity by measurement of TIMI frame count. In intravenous versus intracoronary bolus administration of Eptifibatide during PCI in ACS patients. This non-randomized clinical trial study was performed on 103 patients with acute coronary syndromes who referred to the cardiac emergency ward of Ghaem hospital, Mashhad University of Medical Sciences, and were candidates for urgent coronary angiography and PCI. Forty-eight cases received intracoronary bolus Eptifibatide and 55 intravenous Eptifibatide. TIMI Frame Count and Corrected TIMI Frame Count were used to comparing the effect of these two methods on coronary blood flow velocity. Data were analyzed by SPSS software (version 22). To compare the quantitative variables in the two groups, according to the distribution of variables, the t-test was used if it was normal or the Mann-Whitney test was used if it was not normal. A Chi-square test was also used to compare qualitative variables into two groups. P&lt;0.05 was considered statistically significant. Mean of age, gender, and cardiovascular risk factors were similar in the two groups. There was no significant difference in terms of serum Creatine Kinase MB (CKMB) level, Left Ventricular Ejection Fraction (LVEF), coronary artery lesion length, coronary artery diameter, coronary thrombosis, and coronary artery thrombectomy in two groups. Based on Student's t-test, there was no significant difference between mean TIMI Frame Count in different coronary arteries in the intracoronary and intravenous injection groups (In LAD, P=0.518; For LCX, P=0.576; and in RCA, P=0.964). The complications were observed in 11 patients (22.9%) of the intracoronary injection group and 9 (16.4%) of the intravenous injection group; the difference was not significant (P=0.402). The effects and complications of Eptifibatide were not significantly different in Intracoronary and intravenous administration in ACS patients during PCI and at the time of patients' hospitalization.

The coexistence of obstructive sleep apnea in patients with slow coronary flow: a cross-sectional study

BACKGROUND: Interestingly, obstructive sleep apnea (OSA) and coronary slow-flow (CSF) have similar pathogenic mechanisms, including increased sympathetic activity and endothelial dysfunction. However, the association between OSA and CSF is not known well. If undiagnosed, OSA is a cause of increased cardiovascular morbidity and mortality. We investigated the presence of OSA in the patients diagnosed CSF after coronary angiography. METHODS: The prospective cross-sectional study included 4515 patients admitted angiography laboratory from February 2018 to March December 2019. After coronary angiography of 4515 patients, 336 patients were diagnosed as slow coronary flow. These patients were examined by pulmonology and sleep specialist. Of the 336 patients, 276 patients were found high risk in terms of OSA by using Berlin questionnaire (BQ). Only 75 of 276 patients underwent polysomnography (PSG) testing. Control group patients (n=40) had normal coronary artery and no OSA. RESULTS: Of 4515 patients, 336 (7.4%) met the criteria for CSF. After BQ, 276 of 336 patients had high-score BQ (82.1%). The study group consisted of 276 patients (188 males, 88 females). The mean ages of the study group were 48.48 ±7.61 years. Body mass index (BMI) according to WHO criteria was 33.02±2.18 kg/m2. When 75 patients underwent PSG were divided on two groups as mild OSA and moderate/severe OSA according to respiratory disturbance index (RDI). We found a significant positive correlation between mean corrected TIMI Frame Count (CTFC) and RDI. While CTFC-Lad in mild OSA group was 32.73, CTFC-Lad in moderate/severe OSA group was 35.04 (p=0.022). While CTFC-Cx in mild OSA group was 31.67, CTFC-Cx in moderate/severe OSA group was 35.26 (p=0.001). While CTFC-Rca in mild OSA group was 32.57, CTFC-Rca in moderate/severe OSA group was 36.33 (p<0.001). CONCLUSION: This study revealed the coexistence between CSF and OSA. Moreover, we demonstrated a significant relationship between mean CTFC and RDI. To determine the clinical association of OSA and CSF may be help to understand pathophysiology of CSF.

Evaluation of the Correlation between Serum Concentrations of Asymmetric Dimethylarginine and Corrected TIMI Frame Count in Patients with Slow Coronary Flow.

Coronary slow flow (CSF) is an important angiographic entity that is characterized by delayed opacification of coronary arteries in the absence of epicardial occlusive disease. Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide synthase. Elevated levels of ADMA cause the induction of endothelial dysfunction and thus promote atherosclerosis. This study was aimed at determining the role of ADMA in the development of CSF. One hundred twenty-nine subjects who fulfilled the inclusion criteria were enrolled in this study. According to coronary angiography results, these subjects were divided into five groups. The serum concentration of ADMA was measured in these subjects. In this study, there was no significant correlation between serum concentrations of ADMA and mean corrected TIMI frame count (CTFC) (P > 0.05). However, the ADMA level was significantly correlated with CTFC in the left anterior descending (LAD) coronary artery in patients with CSF (r = −0.381, P = 0.045). Also, plasma ADMA levels were significantly higher in patients with CSF and without CAD compared to patients without CSF and with CAD (50-90%) (P = 0.034). Besides, serum concentrations of ADMA were significantly higher in subjects with BMI < 25 kg/m2 compared with those having BMI > 30 kg/m2 (P = 0.003). It was also shown that the levels of ADMA were significantly higher in subjects with age as a cardiovascular risk factor compared with those without this risk factor (P = 0.024). Further studies with larger population sizes are needed to confirm the present findings on the association between the serum concentrations of ADMA and CSF.

Coronary Blood Flow Measurement in Conventional Coronary Angiograms by a New Method Based on Contrast Density Detection. A Physiological Insight.

ResumoFundamento O grau de fluxo TIMI e a contagem quadro a quadro TIMI corrigida (CTFC) são métodos amplamente utilizados para avaliar o fluxo sanguíneo coronariano angiográfico. A medição do fluxo sanguíneo coronariano (FSC) na coronariografia (CAG) padrão despertou grande interesse recentemente, tentando combinar o conceito de CTFC com novos métodos para pós-angioplastia e avaliação da síndrome cardíaca X. Além disso, o fluxo coronariano lento é considerado um critério importante para a angina microvascular.Objetivo Explorar uma nova abordagem de medição angiográfica quantitativa do FSC com base na detecção densitométrica de contraste na CAG offline, usando um software acessível para obter uma avaliação mais precisa e confiável do FSC.Métodos Trinta pacientes foram estudados e divididos em 2 grupos: fluxo sanguíneo coronariano normal (FN) e fluxo sanguíneo coronariano lento (FL), de acordo com a definição da CTFC. O MD foi aplicado à amostra do estudo para diferenciar entre FN e FL. A estatística não paramétrica foi usada para avaliar diferenças entre os grupos com p<0,05.Resultados O valor de referência normal do MD obtido para o fluxo sanguíneo coronariano foi de 9 [5–10] quadros. Os grupos FN vs. FL foi comparado e expresso como mediana [intervalo interquartil], para a artéria descendente anterior esquerda: 10 [7–11] vs. 21 [8–33]; p=0,016; artéria circunflexa: 9 [4–13] vs. 14 [11–30]; p=0,012 e artéria coronária direita: 5 [3–11] vs. 13 [8–26]; p=0,009.Conclusão O MD mostrou a viabilidade de medir o fluxo sanguíneo coronariano com precisão, consistência e reprodutibilidade em um angiograma coronariano padrão, mostrando a capacidade adicional de diferenciar FN de FL em pacientes com dor precordial e artérias coronárias normais. (Arq Bras Cardiol. 2020; 115(3):503-512)

Balloon Deflation Strategy during Primary Percutaneous Coronary Intervention in Acute ST-Segment Elevation Myocardial Infarction: A Randomized Controlled Clinical Trial and Numerical Simulation-Based Analysis.

Background Primary percutaneous coronary intervention (PCI) is the best available reperfusion strategy in patients with acute ST-segment elevation myocardial infarction (STEMI). However, PCI is associated with a serious problem known as no-reflow phenomenon, resulting in poor clinical and functional outcomes. This study aimed to compare the influences of different balloon deflation velocity on coronary flow and cardiovascular events during primary PCI in STEM as well as transient hemodynamic changes in in vitro experiments. Method and Results. 211 STEMI patients were randomly assigned to either a rapid or a slow balloon deflation group during stent deployment. The primary end point was coronary flow at the end of PCI procedure, and secondary end points included myocardial infarct size. Transient hemodynamic changes were evaluated through an in vitro experimental apparatus and a computer model. In clinical practice, the level of corrected TIMI frame count (cTFC) in slow balloon deflation after primary PCI was significantly lower than that of rapid balloon deflation, which was associated with smaller infarct size. Numerical simulations revealed that the rapid deflation led to a sharp acceleration of flow in the balloon-vessel gap and a concomitant abnormal rise in wall shear stress (WSS). Conclusion This randomized study demonstrated that the slow balloon deflation during stent implantation improved coronary flow and reduced infarct size in reperfused STEMI. The change of flow in the balloon-vessel gap and WSS resulted from different balloon deflation velocity might be partly accounted for this results.

Ticagrelor versus clopidogrel in patients with STEMI treated with thrombolysis: the MIRTOS trial.

We aimed to demonstrate whether coronary microvascular function is improved after ticagrelor administration compared to clopidogrel administration in STEMI subjects undergoing thrombolysis. MIRTOS is a multicentre study of ticagrelor versus clopidogrel in STEMI subjects treated with fibrinolysis. We enrolled 335 patients <75 years old with STEMI eligible for thrombolysis, of whom 167 were randomised to receive clopidogrel and 168 to receive ticagrelor together with thrombolysis. Primary outcome was the difference in post-PCI corrected TIMI frame count (CTFC). All clinical events were recorded in a three-month follow-up period. From the 335 patients who were randomised, 259 underwent PCI (129 clopidogrel and 130 ticagrelor) and 154 angiographies were analysable for the study primary endpoint. No significant difference was found between the clopidogrel (n=85) and ticagrelor (n=69) groups for CTFC (24.33±17.35 vs 28.33±17.59, p=0.10). No significant differences were observed in MACE and major bleeding events between randomisation groups (OR 2.0, 95% CI: 0.18-22.2, p=0.99). Thrombolysis with ticagrelor in patients <75 years old was not able to demonstrate superiority compared to clopidogrel in terms of microvascular injury, while there was no difference between the two groups in MACE and major bleeding events. ClinicalTrials.gov Identifier: NCT02429271. EudraCT Number 2014-004082-25.

Impairment of coronary flow and left ventricular function in patients with slow coronary flow phenomenon and other types of microvascular angina

Purpose: We aimed at assessing the impairment in coronary flow and left ventricular function in patients without obstructive coronary disease on anti-ischemic treatment admitted with diagnosis unstable angina. Material and methods: The epicardial coronary flow was evaluated in 71 patients with unstable angina in absence of coronary stenosis &gt;50% applying the methods the corrected TIMI frame count and systolic arrest of coronary flow at coronary angiography. The abnormalities in the diastolic function were assessed by echocardiography using PW-Doppler of the diastolic mitral flow and tissue Doppler imaging. Results: The early diastolic velocity of interventricular septum (E’sept) and left ventricular free wall (E’ lat) were reduced in the SFLVH group compared to SCFP and the patients with normal coronary flow. Significant difference was found in between the patients with SFLVH and SCFP regarding DT and A-wave velocity in sub-analysis. The epicardial coronary flow of the patients with SFLVH was as tendency impaired compared to SCFP. The therapy with β- blocker alone or combined with calcium channel blocker or nitrate did not influence either cardiac function or coronary flow in this analysis. Conclusion: Slower left ventricular relaxation is typical for the patients with microvascular angina and left ventricular hypertrophy associated with hypertension on treatment compared to SCFP and patients with normal coronary flow.

Influences of different dose of tirofiban for acute ST elevation myocardial infarction patients underwent percutaneous coronary intervention.

Tirofiban is widely used in patients with acute ST elevation myocardial infarction (STEMI) underwent percutaneous coronary intervention (PCI). This drug can efficiently improve myocardial perfusion and cardiac function, but its dose still remains controversial. We here investigated the effects of different dose of tirofiban on myocardial reperfusion and heart function in patients with STEMI. A total of 312 STEMI patients who underwent PCI in our hospital from March 2017 to March 2018 were enrolled and randomly divided into control group (75 cases, 0 μg/kg), low-dose group (79 cases, 5 μg/kg), medium-dose group (81 cases, 10 μg/kg) and high-dose group (77 cases, 20 μg/kg). The infarction-targeted artery flow grade evaluated by thrombolysis in myocardial infarction (TIMI), corrected TIMI frame count (CTFC) and sum-ST-segment resolution were recorded. At Day 7 and Day 30 after PCI, the left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter, left ventricular end systolic diameter, major adverse cardiovascular events and the hemorrhage and thrombocytopenia were also evaluated. After PCI, the rate of TIMI grade 3, CTFC and incidence of sum-ST-segment resolution > 50% of high-dose group were significantly higher than those of control group, low-dose group and medium-dose group (P < .05), and the CTFC of medium -dose group were significantly higher than that of control group, low-dose group (P < .05). Moreover, the LVEF, left ventricular end diastolic diameter and left ventricular end systolic diameter of high-dose group were significantly improved than those of other groups, and the LVEF of medium-dose group was significantly superior to that of low-dose group (P < .05). However, the incidence of major adverse cardiac events in high-dose group was significantly decreased, while the hemorrhage and incidence of thrombocytopenia of high-dose group were significantly higher than those of other 3 groups (P < .05). The tirofiban can effectively alleviate the myocardial ischemia-reperfusion injury and promote the recovery of cardiac function in STEMI patients underwent PCI. Although the high-dose can enhance the clinical effects, it also increased the hemorrhagic risk. Therefore, the rational dosage application of tirofiban become much indispensable in view of patient's conditions and hemorrhagic risk, and a medium dose of 10 μg/kg may be appropriate for patients without high hemorrhagic risk.

Long-term outcome of patients with ST-segment elevation myocardial infarction treated with low-dose intracoronary thrombolysis during primary percutaneous coronary intervention: the 5-year results of the DISSOLUTION Trial.

We tested the hypothesis that adjunctive thrombolysis at time of primary percutaneous coronary intervention (PCI) may affect favourably the long-term outcome of patients with ST elevation myocardial infarction (STEMI). To this end, we undertook a substudy of the DISSOLUTION (Delivery of thrombolytIcs before thrombectomy in patientS with ST-segment elevatiOn myocardiaL infarction Undergoing primary percuTaneous coronary interventION) trial. A total of 95 patients were randomized to local delivery of urokinase (n = 48) or placebo (n = 47). After PCI, a greater proportion of patients receiving urokinase had an improvement in myocardial perfusion, as indicated by a significantly higher final Thrombolysis in myocardial infarction (TIMI) grade 3, myocardial blush grade, and 60-min ST-segment resolution > 70%, as well as lower corrected TIMI frame count. At 1-year echocardiography, urokinase-treated patients exhibited significantly lower LV dimension, as well as higher LV ejection fraction and wall motion score index as compared with placebo-treated patients. At 5years, major acute cardiovascular events (MACEs) were significantly less common in the urokinase group (P = 0.023), mainly due to a lower occurrence of hospitalisation for heart failure (P = 0.038). Multivariate analysis showed that factors independently associated with 5-year occurrence of MACEs were LV remodelling at 1-year echocardiography (P = 0.0001), 1-year LV ejection fraction (P = 0.0001), TIMI grade flow 0-2 (P = 0.0019), and age at time of PCI (P = 0.0173). In conclusion, low-dose intracoronary urokinase during primary PCI is associated with a more favourable 5-year outcome of patients with STEMI.