post-PCI Thrombolysis In Myocardial Infarction Flow Grade Research Articles

Evaluation of Coronary Flow Level with Mots-C in Patients with STEMI Undergoing Primary PCI.

The protective effects of mitochondrial open reading frame of the 12S rRNA-c (MOTS-C) on cardiovascular diseases have been shown in numerous studies. However, there is little documentation of the relationship between MOTS-C and coronary blood flow in ST-segment elevation myocardial infarction (STEMI). We aimed to investigate the role of MOTS-C, which is known to have cytoprotective properties in the pathogenesis of the no-reflow phenomenon, by comparing the coronary flow rate and MOTS-C levels in patients with STEMI submitted to primary PCI. 52 patients with STEMI and 42 patients without stenosis >50% in the coronary arteries were included in the study. The STEMI group was divided into two groups according to post-PCI TIMI (Thrombolysis In Myocardial Infarction) flow grade:(i) No-reflow: grade 0, 1, and 2 and (ii) grade 3(angiographic success). A p value of <0.05 was considered significant. MOTS-C levels were significantly lower in the STEMI group compared to the control group (91.9 ± 8.9 pg/mL vs. 171.8±12.5 pg/mL, p<0.001). In addition, the Receiver Operating Characteristics (ROC) curve analysis indicated that serum MOTS-C levels had a diagnostic value in predicting no-reflow (Area Under the ROC curve [AUC]:0.95, 95% CI:0.856-0.993, p<0.001). A MOTS-C ≥84.15 pg/mL measured at admission was shown to have 95.3% sensitivity and 88.9% specificity in predicting no-reflow. MOTS-C is a strong and independent predictor of no-reflow and in-hospital MACE in patients with STEMI. It was also noted that low MOTS-C levels may be an important prognostic marker of and may have a role in the pathogenesis of STEMI.

Usefulness of fibrinogen-to-albumin ratio to predict no-reflow and short-term prognosis in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

No-reflow is one of the major complications of primary percutaneous coronary artery intervention (pPCI) in the treatment of acute ST-segment elevation myocardial infarction (STEMI). Fibrinogen-to-albumin ratio (FAR) has currently emerged as a novel inflammatory marker to predict inflammation in chronic diseases. This study aimed to investigate whether admission FAR values predicts angiographic no-reflow and short-term prognosis in all STEMI patients. A total of 510 consecutive STEMI patients who underwent successful pPCI between September 2016 and May 2018 were included in this study. Patients were divided into groups based on thrombolysis in myocardial infarction (TIMI) flow grades after pPCI. No-reflow was defined as a post-PCI TIMI flow grade of 0, 1, or 2. Angiographic success was defined as TIMI flow grade 3. Fibrinogen, hs-CRP, and admission FAR values were significantly higher among patients with no-reflow. On multivariate analysis, admission FAR was an independent predictor of angiographic no-reflow (p < 0.001). Receiver-operating characteristics analysis revealed the cut-off value of admission FAR was a predictor of no-reflow with a sensitivity of 79.59% and a specificity of 69.42%. In multivariable Cox regression models adjusted for potential confounders, admission FAR values, and LVEF, hs-CRP was independently and positively associated with the 30-day all-cause mortality. Admission FAR was associated independently and significantly with angiographic no-reflow and short-term mortality in patients with STEMI undergoing pPCI.

Myocardial blush and microvascular reperfusion following manual thrombectomy during percutaneous coronary intervention for ST elevation myocardial infarction: insights from the TOTAL trial.

Thrombectomy during primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) has been thought to be an effective therapy to prevent distal embolization and improve microvascular perfusion. The TOTAL trial (N = 10 732), a randomized trial of routine manual thrombectomy vs. PCI alone in STEMI, showed no difference in the primary efficacy outcome. This angiographic sub-study was performed to determine if thrombectomy improved microvascular perfusion as measured by myocardial blush grade (MBG). Of the 10 732 patients randomized, 1610 randomly selected angiograms were analysable by the angiographic core laboratory. Primary outcomes included MBG and post-PCI thrombolysis in myocardial infarction (TIMI) flow grade. Secondary outcomes included distal embolization, PPCI complications, and each component of the complications. The primary end point of final myocardial blush (221 [28%] 0/1 for thrombectomy vs. 246 {30%} 0/1 for PCI alone group, P = 0.38) and TIMI flow (712 [90%] TIMI 3 for thrombectomy vs. 733 [89.5%] TIMI 3 for PCI alone arm, P = 0.73) was similar in the two groups. Thrombectomy was associated with a significantly reduced incidence of distal embolization compared with PCI alone (56 [7.1%] vs. 87 [10.7%], P = 0.01). In multivariable analysis, distal embolization was an independent predictor of mortality (HR 3.00, 95% CI 1.19-7.58) while MBG was not (HR 2.73, 95% CI 0.94-5.3). Routine thrombectomy during PPCI did not result in improved MBG or post-PCI TIMI flow grade but did reduce distal embolization compared with PCI alone. Distal embolization and not blush grade is independently associated with mortality.

Microvascular obstruction in patients with non-ST-elevation myocardial infarction: a contrast-enhanced cardiac magnetic resonance study.

The aim of the study was to assess the frequency and predictive factors of microvascular obstruction (MVO) in patients with non-ST-segment elevation myocardial infarction (NSTEMI). This study included 190 consecutive patients with NSTEMI who underwent percutaneous coronary intervention (PCI) within 24 h after admission and cardiac magnetic resonance (CMR) imaging, 4.1 days after angiography. MVO was defined using the CMR criteria. MVO was detected 26 of 190 patients (13.8%). Patients with MVO had higher peak high-sensitivity troponin T, creatine-kinase and creatine kinase-myocardial band levels and higher proportions of those with baseline thrombolysis in myocardial infarction (TIMI) flow grade 0-1, absence of collateral circulation, post-PCI TIMI flow grade <3, myocardial blush grade <3 and angiographic no-reflow than patients without MVO. Patients with MVO had larger initial area at risk [median (25th-75th percentiles), 23.9% (17.4-33.9%) vs. 16.1% (7.8-27.7%), P = 0.018] and infarct size [11.4% (6.6-19.2%) vs. 1.4% (0-4.7%) of the left ventricle, P < 0.001] than patients without MVO. In multivariable analysis, the culprit lesion localization in the circumflex coronary artery [adjusted odds ratio (OR) 13.71, 95% confidence interval 2.91-64.58, P < 0.001] and the infarct size [adjusted OR 3.37 (1.80-6.29), P < 0.001, for each 5% of the left ventricle] were independently associated with the increased risk for MVO. In patients with NSTEMI undergoing early PCI, the MVO defined by CMR imaging was present in 13.8 % of the patients. The localization of culprit lesion in the circumflex coronary artery and larger infarct size were independently associated with the increased risk for MVO.

Association of Mean Platelet Volume and Pre- and Postinterventional Flow With Infarct-Related Artery in ST-Segment Elevation Myocardial Infarction

Platelets play a role in the pathogenesis of ST-segment elevation myocardial infarction (STEMI). We assessed the relationship between mean platelet volume (MPV) on admission and pre- and postinterventional flow with the infarct-related artery (IRA) in patients with STEMI. We prospectively included 840 patients with STEMI who underwent primary percutaneous coronary intervention (PCI). The patients were divided into 3 groups according to MPV tertiles. Pre- and post-PCI Thrombolysis In Myocardial Infarction (TIMI) flow grade was determined. Initial TIMI flow grade 3 was accepted as patent IRA. After the primary PCI, normal flow was defined as post-PCI TIMI flow 3. When the MPV was increased, the incidence of pre-PCI patent IRA (P = .004) and post-PCI normal TIMI flow (P < .001) was significantly decreased. Multivariate analysis showed that MPV was independently associated with post-PCI TIMI flow grade.

Analysis of the factor of effective thrombus aspiration on patients in primary percutaneous coronary intervention

Objective To find the factors lowering the rate of effective thrombus aspiration in patients with STsegment elevation acute myocardial infarction (STEMI) treated with primary percutaneous coronary intervention(PCI). Method From January to December 2008 , a total of 226 AMI patients from Beijing Anzhen Hospital,treated with primary PCI to aspirate the thrombus from the infracted coronary artery via a cannula, were enrolled in a single center retrospective study. The criterion of successful thrombectomy (device success) was defined as the coronary blood flow of involved vessel after PCI resumed to greater than TIMI grade 1. One hundred seventy-eight patients were assigned to effective thrombus aspiration group, and 48 patients without improvement in coronary blood flow of involved vessel after PCI to control group. Data collected after PCI including the normalization of the elevated ST segment,the use of direct stent, ratio of no-flow/slow flow, intra-coronary administration of Tirofiban and the rate of thrombolysis in myocardial infarction (TIMI) flow grade 3 were analyzed with logistic analysis soas to find out the factors affecting the efficacy of thrombus aspiration. Results There were no significant differences in data before PCI between two groups ( P ＞0.05). Compared with the control group, the factors studied such as smoke, diabetes, the rate of pre-PCI TIMI flow grade 0,the post-PCI ratio of no-reflow/slow flow,and the intra-coronary administration of Tirofiban were fewer significantly in the effective thrombus aspiration group. And the rate of post-PCI TIMI flow grade 3, and the rate of direct stent were higher in the effective thrombus aspiration group. Logistic analysis showed that smoke ( OR = 1.551,95%CI: 1.018 ～ 2. 154, P = 0.012), diabetes ( OR = 1. 132,95%CI:0.276 ～ 3.562, P =0.044), and pre-PCI TIMI flow grade 0 OR = 0.544,95%CI:0.368 ～ 1.911,P = 0.035) were independent factors of effective thrombus aspiration. Conclusions Effective thrombus aspiration may improved the coronary blood flow to TIMI flow grade 3 after PCI and reduce the impaiment of myocardial perfusion, and the factors affecting the efficacy of thrombus aspiration should be paid more attention to and should be minimized to achieve the better clinical outcomes. Key words: Acute myocardial infarction; Primary percutaneous coronary intervention; Thrombus aspiratiou; Effective; ST segment recovery; Direct stem; No-reflow/slow flow; Effect factors

Prior Coronary Artery Bypass Graft Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

We sought to compare outcomes in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) with or without previous coronary artery bypass grafts (CABG). Limited information exists regarding procedural success and clinical outcomes of STEMI patients with CABG undergoing primary PCI. The APEX-AMI (Assessment of Pexelizumab in Acute Myocardial Infarction) trial was a randomized, placebo-controlled trial of pexelizumab in STEMI patients with planned primary PCI: 128 of 5,745 (2.2%) patients had prior CABG. Clinical/procedural characteristics, culprit vessel (infarct-related artery [IRA]), and 90-day clinical outcomes were compared. Patients with previous CABG were more frequently men, older, had a higher incidence of comorbidities and multivessel disease. In patients with versus without prior CABG, PCI was performed less frequently, that is, 78.9% versus 93.9%; of those with prior CABG receiving PCI, Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 was also restored less often, that is, 82.5% versus 91.6% (both p < 0.001). In prior CABG, there was a nearly even designation of the IRA as a bypass graft (n = 63) versus a native vessel (n = 55): IRA post-PCI TIMI flow grade 3 was achieved in 66.7% versus 88.0%, respectively (p = 0.043). Prior CABG patients had increased 90-day death and composite 90-day death/congestive heart failure/shock. Excess death remained significant after multivariable adjustment (hazard ratio: 1.9, 95% confidence interval: 1.08 to 3.33, p = 0.025). When prior CABG patients were stratified by the type of IRA, there was further discrimination of the increased 90-day death, that is, 19% bypass graft (n = 63) versus 5.7% native vessel (n = 55, p = 0.05), respectively. Prior CABG patients with STEMI are less likely to undergo acute reperfusion, have worse angiographic outcomes following primary PCI, and higher 90-day mortality. These findings are especially applicable when the IRA was a bypass graft.

Contribution of angiographic and electrocardiographic parameters of reperfusion to prediction of mortality and morbidity after acute ST-elevation myocardial infarction: Insights from the Assessment of Pexelizumab in Acute Myocardial Infarction trial

Reperfusion with primary percutaneous intervention (PCI) in ST-segment elevation myocardial infarction leads to improved clinical outcomes. The contribution angiographic vs electrocardiographic reperfusion parameters confer on prognosis is unclear. A prespecified subset of the APEX-AMI trial patients was analyzed by independent angiographic and electrocardiographic core laboratories (n = 1,018). Angiographic reperfusion after PCI and electrocardiogram 30 minutes post-PCI were assessed. Of the 941 patients in the angiographic substudy, 796 (85%) attained post-PCI Thrombolysis In Myocardial Infarction (TIMI) flow 3 and 852 (91%) had TIMI Myocardial Perfusion Grade (TMPG) 2/3. There were 664 (71%) patients with residual ST elevation (ST-E) <2 mm. Ninety-day mortality and death/CHF/shock were lower in patients with TIMI flow 3 vs <3 (1.9% vs 6.2%, P = .002; 5.8% vs 10.4%, P = .044) and those with TMPG 2/3 vs 0/1 (2.0% vs 7.9%, P = .001; 6.0% vs 11.9%, P = .028). Patients with residual ST-E <2 mm had similar rates of mortality as those with > or =2 mm (2.3% vs 3.3%, P = .374) but lower rates of death/CHF/shock (5.2% vs 9.6%, P = .013). After multivariable adjustment, only post-PCI TMPG 2/3 was significantly associated with survival (P = .001), whereas residual ST-E (P = .606) and post-PCI TIMI flow grade (P = .086) were not. Conversely, residual ST-E > or =2 mm (P = .012) rather than angiographic reperfusion was associated with the composite of death/CHF/shock events. Angiographic and electrocardiographic estimates of reperfusion with primary PCI in ST-segment elevation myocardial infarction provide different and complementary predictions of morbidity and mortality.

Prognostic value of minimal blood flow restoration in patients with acute myocardial infarction after reperfusion therapy

The prognostic impact of low-flow reperfusion after percutaneous coronary intervention (PCI) in patients with ST-segment elevation acute myocardial infarction (STEMI) is unknown. The aim of the study was to investigate the impact of low-flow reperfusion after PCI in patients with STEMI. This study included 1,761 patients with STEMI with a baseline thrombolysis in myocardial infarction (TIMI) flow grade 0 and no collateral circulation to the infarcted region before primary PCI. The primary outcome was 1-year mortality. At the end of PCI procedure there were 115 patients with post-PCI TIMI flow grade 0; 57 patients with TIMI flow grade 1; 218 patients with TIMI flow grade 2; and 1,371 patients with TIMI flow grade 3. At 1 year there were 36 deaths in patients with TIMI grade 0; 28 deaths in patients with TIMI grade 1; 42 deaths in patients with TIMI grade 2; and 162 deaths in patients with TIMI grade 3 [estimates of mortality 32.6, 49.1, 19.6 and 12.1%, respectively; odds ratio (OR) = 1.76, 95% CI 1.08-2.86, P = 0.02, for TIMI flow grade 1 vs. TIMI flow grade 0]. The Cox proportional hazards model identified post-PCI TIMI flow grade as an independent predictor of 1-year mortality [hazard ratio (HR) = 1.99, 95% CI 1.17-3.28; P = 0.01 for TIMI flow grade 1 vs. TIMI flow grade 0]. Patients with STEMI with totally occluded infarct-related arteries and no collateral blood flow to the infarcted region show a greater mortality with post-PCI TIMI flow grade 1 than TIMI flow grade 0.

Clinical Significance of Post-Procedural TIMI Flow in Patients With Cardiogenic Shock Undergoing Primary Percutaneous Coronary Intervention

We sought to evaluate the impact of post-primary percutaneous coronary intervention (PCI) Thrombolysis In Myocardial Infarction (TIMI) flow grades in the infarct-related artery (IRA) in patients with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock. The clinical implications and correlates of post-procedural TIMI flow grades in patients with STEMI and cardiogenic shock treated with primary PCI have not been elucidated. We evaluated 4,731 STEMI patients with cardiogenic shock undergoing primary PCI at 567 hospitals participating in the American College of Cardiology-National Cardiovascular Database CathPCI Registry to determine the association of post-procedural TIMI flow grades 0 to 2 with in-hospital outcomes. Post-PCI TIMI flow grades 0 to 2 in the IRA were present in 14.7% of patients. Compared with patients with TIMI flow grade 3, those with TIMI flow grades 0 to 2 were more likely to undergo coronary artery bypass graft surgery after PCI (20% vs. 5.4%), and develop renal failure (10.1% vs. 5.1%), cardiac tamponade (1.0% vs. 0.5%), and bleeding requiring blood transfusion (35.2% vs. 21.6%). Unadjusted mortality was more than 2-fold higher with TIMI flow grades 0 to 2 versus TIMI flow grade 3 (63% vs. 27%). There was a graded inverse relationship with TIMI flow in the IRA and the adjusted mortality (odds ratio [OR] for TIMI flow grades 0/1: 5.47 [95% confidence interval (CI): 4.13 to 7.24] and for TIMI flow grade 2: 2.63 [95% CI: 2.02 to 3.42] compared with TIMI flow grade 3). Our study also identified factors associated with post-PCI TIMI flow grades 0 to 2. Lack of procedural success (post-PCI TIMI flow grades 0 to 2 in the IRA) after primary PCI for STEMI among patients with cardiogenic shock is associated with a much higher risk of mortality compared with the risk for patients with normal post-PCI TIMI flow grade 3.

Prognostic Significance of Epicardial Blood Flow Before and After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndromes

The aim of the study was to assess the relationship between baseline and post-procedural Thrombolysis In Myocardial Infarction (TIMI) epicardial blood flow grade and mortality in patients with acute coronary syndromes (ACS) who were treated with early percutaneous coronary intervention (PCI). The impact of baseline and post-procedural TIMI flow grade on mortality in patients with ACS has been insufficiently studied. This prospective registry included 10,455 patients with ACS who underwent coronary angiography and PCI: 2,853 patients with ST-segment elevation acute myocardial infarction, 3,060 patients with non-ST-segment elevation acute myocardial infarction, and 4,542 patients with unstable angina. The primary outcome was 1-year mortality. At 1 year, there were 976 deaths: 117 deaths among patients with TIMI flow grade 0 to 1, 105 deaths among patients with TIMI flow grade 2, and 754 deaths among patients with TIMI flow grade 3 (Kaplan-Meier estimates of mortality 28.3%, 18.4%, and 8.0%, respectively; odds ratio: 1.66, 95% confidence interval [CI]: 1.57 to 1.76, p < 0.001, for TIMI flow grade 0 to 1 vs. TIMI flow grade 2 and odds ratio: 2.51, 95% CI: 2.06 to 3.06, p < 0.001, for TIMI flow grade 2 vs. TIMI flow grade 3). By using the Cox proportional hazards survival model, we identified post-PCI TIMI flow grade (hazard ratio: 0.60, 95% CI: 0.52 to 0.70; p < 0.001, for 1 grade increase in TIMI flow grade) but not baseline TIMI grade (hazard ratio: 1.08, 95% CI: 0.96 to 1.22; p = 0.20, for 1 grade increase in TIMI flow grade) as an independent correlate of 1-year mortality. In patients with ACS treated with early PCI, post-procedural TIMI flow grade but not baseline TIMI flow grade is an independent correlate of 1-year mortality.

Reperfusion after primary angioplasty for ST-elevation myocardial infarction: predictors of success and relationship to clinical outcomes in the APEX-AMI Angiographic Study

We studied the clinical, demographic, and angiographic factors associated with successful reperfusion and the relationship between angiographic indices and clinical outcomes in a subset of the APEX-AMI trial, which tested the efficacy of pexelizumab in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention (PCI). Among 5745 patients enrolled in the trial, 1018 underwent independent quantitative angiographic evaluation by a core laboratory. Successful epicardial reperfusion was defined as TIMI (thrombolysis in myocardial infarction) flow grade 3 or corrected TIMI frame count (cTFC) <28 frames, and successful myocardial reperfusion as TIMI myocardial perfusion grade (TMPG) 2 or 3. TIMI 3 flow after PCI occurred in 85%, cTFC < 28 in 58% (mean cTFC was 27 +/- 20), and TMPG 2 or 3 in 91%. Overall 90 day clinical outcomes were 2.7% for mortality and 8.2% for the composite of death, congestive heart failure (CHF), or shock. After adjustment for baseline characteristics, TMPG 2/3 after PCI was associated with younger age [odds ratio (OR) for 10 year increase 0.75, 95% confidence interval (CI) 0.59-0.96, P = 0.023], pre-PCI TIMI flow 2/3 (OR 3.5, 95% CI 1.7-7.1, P = 0.001), and ischaemic time [for every hour, OR 0.81 (0.69-0.96), P = 0.015]. TMPG 2/3 after PCI was significantly associated with 90 day mortality (adjusted hazard ratio 0.26, 95% CI 0.09-0.78, P = 0.013). Neither post-PCI TMPG nor TIMI flow grade was significantly associated with 90 day death/CHF/shock. Younger age, patent infarct-related artery at presentation, and ischaemic time predicted higher likelihood of successful myocardial perfusion, which was associated with improved survival.