Suboptimal Coronary Flow Research Articles

Postdilatation after stent deployment during primary percutaneous coronary intervention: a systematic review and meta-analysis.

The utilization of postdilatation in primary percutaneous coronary intervention (PCI) is feared to induce suboptimal coronary blood flow and compromise the outcome of the patients. This meta-analysis sought to verify whether postdilatation during primary PCI is associated with worse angiographic or long-term clinical outcomes. Systematic literature searches were conducted on PubMed, The Cochrane Library, ClinicalTrials.gov, EBSCO, and Europe PMC on 10 March 2024. Eligible studies reporting the outcomes of postdilatation among ST-segment elevation myocardial infarction patients were included. The primary outcome was no-reflow condition during primary PCI based on angiographic finding. The secondary clinical outcome was major adverse cardiovascular events (MACEs) comprising all-cause death, myocardial infarction, target vessel revascularization (TVR), and stent thrombosis. Ten studies were finally included in this meta-analysis encompassing 3280 patients, which was predominantly male (76.6%). Postdilatation was performed in 40.7% cases. Postdilatation was associated with increased risk of no-reflow during primary PCI [Odd Ratio (OR) = 1.33, 95% Confidence Interval (CI): 1.12-1.58; P = .001)]. Conversely, postdilatation had a tendency to reduce MACE (OR = 0.70, 95% CI: 0.51-0.97; P = .03) specifically in terms of TVR (OR = 0.41, 95% CI: 0.22-0.74; P = .003). No significant differences between both groups in relation to mortality (OR = 0.58, 95% CI: 0.32-1.05; P = .07) and myocardial infarction (OR = 1.5, 95% CI: 0.78-2.89; P = .22). Postdilatation after stent deployment during primary PCI appears to be associated with an increased risk of no-reflow phenomenon after the procedure. Nevertheless, postdilatation strategy has demonstrated a significant reduction in MACE over the course of long-term follow-up. Specifically, postdilatation significantly decreased the occurrence of TVR. Key messages: What is already known on this topic? Optimizing stent deployment by performing postdilatation during percutaneous coronary intervention (PCI) is essential for long-term clinical outcomes. However, its application during primary PCI is controversial due to the fact that it may provoke distal embolization and worsen coronary blood flow. What this study adds? In this systematic review and meta-analysis of 10 studies, we confirm that postdilatation during primary PCI is associated with worse coronary blood flow immediately following the procedure. On the contrary, this intervention proves advantageous in improving long-term clinical outcomes, particularly in reducing target vessel revascularization. How this study might affect research, practice, or policy? Given the mixed impact of postdilatation during primary PCI, this strategy should only be applied selectively. Future research should focus on identifying patients who may benefit from such strategy.

Factors affecting TIMI (Thrombolysis In Myocardial Infarction) flow grade in patients undergoing primary PCI (Percutaneous Coronary Intervention).

Objective: To determine the causes of normal blood flow in coronary arteries in patients presenting with STEMI and receiving pPCI. Study Design: Observational study conducted retrospectively. Setting: National Institute of Cardiovascular Disease (NICVD) Karachi, Cath Lab. Period: August 17 2020 to November 2020. Material & Methods: Data was obtained from patients presented to the emergency department with STEMI and experienced primary PCI in last two years from January 2016 to Decemebr 2018.Social Sciences (SPSS) version 19 was used analyze these data.Th in those patients who had suboptimal coronary blood flow. Young patients <40 years of age had more (14%) normal coronary blood flow as compared to elders i.e >40 years. Diabetes mellitus, Hypertension, and smoking had no significant impact on coronary blood flow in these patients. Conclusion: In this study, it was found that most of the coronary arteries had abnormal blood flow during primary PCI. Multiple factors are affecting the blood flow in coronaries. The onset of symptoms and the time presented in the hospital was the main factors. Further studies are required to find more reasons for having normal blood flow in coronaries in STEMI.

Risk Factors of Suboptimal Coronary Blood Flow after a Percutaneous Coronary Intervention in Patients with Acute Anterior Wall Myocardial Infarction.

Primary percutaneous coronary intervention (PCI) is regarded as the most preferred strategy in ST-segment elevation myocardial infarction (STEMI). Thrombolysis in Myocardial Infarction (TIMI) flow grade has been an important and cohesive predictor of outcomes in STEMI patients. We sought to evaluate potential variables associated with the risk of suboptimal TIMI flow after PCI in patients with anterior wall STEMI. We evaluated 107 patients admitted to our hospital between 1 January 2019 and 31 December 2021 with a diagnosis of anterior wall STEMI treated with primary PCI. Suboptimal TIMI flow grade (≤2) after PCI occurred in 14 (13%) patients while grade 3 was found in 93 (87%) of them presenting with anterior wall STEMI. Failure to achieve optimal TIMI 3 flow grade after PCI was associated with lower TIMI grade prior to PCI (OR 0.5477, 95% CI 0.2589-0.9324, p = 0.02), greater troponin concentration before (OR 1.0001, 95% CI 1-1.0001, p = 0.0028) and after PCI (OR 1.0001, 95% CI 1-1.0001, p = 0.0452) as well as lower mean minimal systolic blood pressure (OR 0.9653, 95% CI 0.9271-0.9985, p = 0.04). Among predictors of suboptimal TIMI flow grade after PCI, we noted lower TIMI grade flow pre-PCI, greater serum troponin concentrations in the periprocedural period and lower mean minimal systolic blood pressure.

Clinical and Angiographic Predictors of suboptimal Coronary Flow After Primary Percutaneous Coronary Intervention in Patients with ST-Elevation Myocardial Infarction.

This study aimed to investigate the clinical and angiographic characteristics of patients with ST-elevation myocardial infarction who experienced primary percutaneous coronary intervention failure. This retrospective observational study was derived from the Primary Angioplasty Registry of Sina Hospital (PARS). A total of 548 consecutive patients with ST-elevation myocardial infarction who underwent primary percutaneous coronary intervention between November 2016 and January 2019 were evaluated. Percutaneous coronary intervention failure was defined as Thrombolysis in Myocardial Infarction (TIMI) flow ≤ 2 or corrected TIMI frame count (cTFC) ≥ 28. The study population consisted of 458 (83.6%) males and 90 (16.4%) females with a mean age of 59.2 ± 12.49 years. TIMI flow 3 was achieved in 499 (91.1%) patients after the procedure, while 49 (8.9%) patients developed TIMI ≤ 2. The findings showed that cTFC ≥ 28 was present in 50 (9.1%) patients, while 489 (89.2%) patients had cTFC < 28. Multiple regression analysis shows that age 1.04 (1.01, 1.07), duration of pain onset to first medical contact time 1.04 (1.00, 1.18), and left anterior descending artery involvement 3.15 (1.21, 8.11) were independent predictors of TIMI ≤ 2. Even though TIMI ≤ 2 was uncommon among the study population, it was associated with adverse in-hospital outcomes. The results indicate that earlier emergency medical service arrival and shorter transfer time to the referral center can dramatically reduce the primary percutaneous coronary intervention failure rate.

Predictors of Suboptimal Coronary Blood Flow during Primary Percutaneous Intervention

Background and aim: Suboptimal coronary blood flow following first percutaneous coronary intervention (PCI) is a multivariate phenomenon with several causes. Despite substantial research, recognized modifiable risk factors and an effective management plan are lacking. The present study intended to determine the several causes of suboptimal coronary blood flow during primary percutaneous intervention. Patients and Method: A retrospective study was carried out on 486 STEMI patients in the Interventional Cardiology Department, MTI-Hayatabad Medical Complex, Peshawar from June 2021 to May 2022. Patients (age&gt;20 years) presented with initial percutaneous coronary intervention within 12 hours after onset of symptoms were enrolled. Patients’ physical examination, medical history, different risk factors, vital signs assessment, echocardiography, Killip class, laboratory investigation, and post-procedural ECG were recorded along with PCI data and associated catheterization. Clinical outcomes included MACE, ischemia-driven target vessel revascularization, reinfection, cardiac mortality, and post-catheterization were recorded. Descriptive statistics was done in SPSS version 26. Results: Of the total 486 STEMI patients, there were 412 (84.8%) male and 74 (15.2%) females. The overall mean age was 52.62± 8.64 years. The incidence of suboptimal flow (TIMI flow ≤2) and optimal flow (TIMI-3 flow) were 112 (23%) and 374 (77%) respectively. Age [OR 1.041/year: p&lt;0.001], total stent length [OR 1.019 per 1 mm], low SBP [OR 1.021 per mm Hg], thrombus burden grade [OR 1.78], and baseline TIMI flow (≤1) [OR 1.72; p=0.021] were suboptimal flow independent predictors. Cardiac mortality and MACE were significantly higher after 30-days in suboptimal flow as compared to optimal flow. The prevalence of in-hospital mortality in suboptimal flow and optimal flow was 9.1% and 2.1% respectively. Conclusion: The present study found that suboptimal coronary flow after first PCI is substantially associated with higher in-hospital and cardiovascular mortality in STEMI. The most significant predictor of poor coronary flow is predilatation prior to stenting. Keywords: Suboptimal coronary flow, Primary percutaneous intervention, Predictors

Suboptimal coronary flow after PCI in STEMI patients: clinical implications and predictors

Abstract Background Even in experienced angioplasty centers, percutaneous coronary intervention (PCI) in the acute setting of ST-elevation myocardial infarctions (STEMI) is associated with a low, but still significant rate of suboptimal coronary flow. Identification of its clinical impact and potential modifiable risk factors is important. Purpose To evaluate the clinical impact of suboptimal coronary flow after PCI in STEMI patients and to access potential predictors of suboptimal coronary flow. Methods We retrospectively evaluated 103 hospitalized patients with acute STEMI who were admitted to our center between 2018 and 2019 and underwent PCI. Coronary flow was accessed using the Thrombolysis in myocardial infarction (TIMI) Flow Grading System. Patients were divided into suboptimal patency of the culprit-vessel, defined as TIMI flow ≤2 (group 1, n=8 (7,8%)) and optimal patency of the culprit-vessel defined as TIMI flow 3 (group 2, n=95 (92,2%)). Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. Results Mean age 58,15±12,6 years and 85,4% were males. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes, 17 (15,5%) were obese and 4 (3,9%) had chronic kidney disease. The revascularization strategy was primary PCI in 55 (54,4%) patients and fibrinolytic therapy with facilitated PCI in 48 (46,6%) patients. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). Angiographic no-reflow after PCI was 3,0%. Intrahospital cardiovascular death occurred in 4 (3,9%) patients and was significantly associated with suboptimal flow (p=0,036) and there was no association with stent thrombosis. Predictors of suboptimal flow were higher blood urea nitrogen, creatinine and GFR at hospital admission (p=0,017 and p=0,012), peak creatinine (p=0,012) and stent length (p=0,038). Suboptimal flow was associated with higher Zwolle score (p=0,010) and ischemic Paris score (p=0,036). Conclusion Failure to achieve optimal culprit-vessel patency after PCI in STEMI patients, although infrequent, is associated with increased hospital cardiovascular death. Longer stents could be and important modified risk factor. Renal dysfunction is an important comorbidity that should be promptly identified and could be partially improved with medical treatment. Funding Acknowledgement Type of funding sources: None.

Impact of hyperuricemia on coronary blood flow and in-hospital mortality in patients with acute myocardial infarction undergoing percutaneous coronary intervention

BackgroundAlthough serum uric acid (UA) is considered as a risk factor for cardiovascular disease, few data exist regarding the relationship between hyperuricemia, coronary blood flow, and subsequent outcome in patients with acute myocardial infarction (AMI). The purpose of our study is to assess whether hyperuricemia is associated with suboptimal coronary flow and increased risk of mortality in patients with AMI after percutaneous coronary intervention (PCI). MethodsUsing the Rural AMI registry data, 989 consecutive patients with AMI who underwent emergent PCI and had UA measurement at admission were analyzed. We defined hyperuricemia as serum UA ≥7.0 mg/dL in men and ≥ 6.0 mg/dL in women. The primary endpoint was suboptimal coronary flow, defined as post PCI Thrombosis In Myocardial Infarction flow grade ≤ 2. The secondary outcome was in-hospital mortality. ResultsHyperuricemia was found in 249 (25.2%) patients. Patients with hyperuricemia were more often complicated with cardiogenic shock compared with those without (16.9% vs. 7.4%, p < 0.001). In addition, the median high-sensitivity C-reactive protein was significantly higher in patients with hyperuricemia (0.18 mg/dL; IQR, 0.09–0.71 mg/dL) than in those without (0.14 mg/dL; IQR, 0.07–0.41 mg/dL, p < 0.05). Under these conditions, the prevalence of suboptimal coronary flow after PCI (17.3% vs. 10.1%, p < 0.05) and in-hospital mortality (10.8% vs. 3.6%, p < 0.001) were significantly higher in patients with hyperuricemia compared with those without. Multivariable logistic regression analysis revealed that hyperuricemia was significantly associated with suboptimal coronary flow [odds ratio (OR), 1.60; 95% confidence interval (CI), 1.02–2.49; p < 0.05] and in-hospital mortality (OR, 2.08; 95% CI, 1.05–4.12; p < 0.05). ConclusionsAssessment of serum UA upon admission provides useful information for predicting suboptimal coronary flow and in-hospital mortality in patients with AMI undergoing PCI.

Epigenetic interaction of miRNA-26a and P2Y12 gene DNA methylation on platelet reactivity under clopidogrel and their impact to the coronary flow after primary PCI in STEMI

Abstract Background Epigenetic factors such as miRNA-26A and P2Y12 DNA methylation play role in pathophysiology of cardiovascular disease. Clopidogrel-resistance is associated with worse cardiovascular outcome. The interactions between the expression of platelet miRNA-26a and P2Y12 DNA methylation to clopidogrel resistance and post procedural TIMI flow in STEMI patients undergoing primary PCI is unclear. Purpose To define interaction of epigenetic factors micro-RNA (miRNA)-26a expression and P2Y12 gene DNA methylation to the platelet reactivity under clopidogrel therapy, and their impact on the coronary flow after Primary PCI in patients with STEMI. Methods We studied STEMI patients who underwent primary PCI, receiving 600 mg loading dose of clopidogrel. Platelet reactivity assessed by VerifyNow P2Y12. Realtime PCR was performed to measure the expression of platelet miR-26a and DNA methylation of P2Y12 gene. Postprocedural epicardial coronary flow was assessed semi quantitatively. Results There were 100 patients were recruited. Among them, 59% have high miRNA-26a platelet expression, 60% had no methylation in their P2Y12 gene, and 27% had high platelet reactivity index under clopidogrel therapy. There was association between high miR-26a expression and reduced platelet inhibition under clopidogrel (OR 4.2, p&amp;lt;0.01), but not with DNA methylation of P2Y12 gene. High platelet reactivity index under clopidogrel therapy was associated with suboptimal coronary flow after primary PCI in STEMI patients (OR 3.3, p&amp;lt;0.05). Conclusions High miRNA-26a platelet expression, but not DNA methylation of P2Y12 gene, in patients with acute STEMI have significant association with high platelet reactivity under clopidogrel therapy. Furthermore, high platelet reactivity under clopidogrel is associated with suboptimal coronary flow in STEMI patients undergoing primary PCI. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Harapan Kita Honor Research Grant

Characteristics, predictors and outcomes after unprotected left main stem primary percutaneous coronary intervention

Abstract Background Reports about outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for unprotected left main (ULM) coronary artery are limited. We aimed to investigate the characteristics, in-hospital and the long-term outcomes of these patients. Methods From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 111 pts (0.96%) who undergone primary PCI for ULM culprit lesion. The short- and the long-term outcomes in this subset was evaluated and compared to 9463 (82.5%) patients undergoing pPCI for lesions located in other segments (Non-LM group). Technical success was defined as final TIMI 3 flow in both, left main and distal vessels, anterior descending and circumflex artery, without significant residual stenosis (&amp;gt;20% following balloon angioplasty or stent implantation) and side branch compromise (residual stenosis &amp;gt;75%). Results Patients with ULM were older and more likely to present as Non-ST-elevation MI (77% vs. 93%; p&amp;lt;0.000) and in cardiogenic shock (40% vs. 2.2%; p&amp;lt;0.000), having less occlusive disease with TIMI 0–1 flow prior to PCI (44% vs. 78%; p&amp;lt;0.000) compared to Non-LM patients. Also, greater procedure complexity was observed with longer lesions &amp;gt;20mm (50% vs. 29%; p&amp;lt;0.000), more intraluminal thrombus (86% vs. 45%; p&amp;lt;0.000), greater number (1,48±0,9 vs. 1,28±0,7; p&amp;lt;0.01) and longer stents (30,5±15,8 vs. 27,4±14,3; p=0.028), more GP IIb/IIIa inhibitors (32% vs. 23%; p=0.022), intra-aortic counterpulsations (7% vs. 0.6%; p&amp;lt;0.000) and contrast media used (202±96 vs. 172±66; p&amp;lt;0.000) in ULM group. Despite obtaining comparable rates of final TIMI 3 flow in main branch (91.9% vs. 95.4%; p=0.084), patients with LMCA had significantly higher in-hospital (27% vs. 4.7%: p&amp;lt;0.000), and one-year all-cause mortality (41% vs. 11%: p&amp;lt;0.000), but for the remaining duration of clinical follow-up (available for 97.8% pts, median duration 51±37 months) survival rates were comparable between ULM and Non-LM pts (18% vs. 15%: p=0.506) (Figure 1). Regression analysis showed that final TIMI 3 in main branch at 30 days (HR 0.05 [95% CI 0.005–0.604]; p=0.018), while peri-procedural cardiogenic shock (hazard ratio (HR) 8.3 [95% CI 2.5–28.1]; p=0.001), creatinine clearance &amp;lt;60 ml/min (HR 7.5 [95% CI 2.3–25.1]; p=0.001) and technical success (HR 0.16 [95% CI 0.45–0.57]; p=0.005) at 5 years, independently predicted mortality in ULM patients. Conclusions Despite performance of primary PCI, patients with MI due to ULM lesions are associated with worse in-hospital and one-year mortality but following that period mortality was comparable to control group. Suboptimal final coronary flow best predicted the 30 day, while peri-procedural cardiogenic shock, renal dysfunction at admission and suboptimal technical procedure result, predicted long-term mortality in these patients. Figure 1 Funding Acknowledgement Type of funding source: None

Predictors of suboptimal coronary blood flow after primary angioplasty and its implications on short-term outcomes in patients with acute anterior STEMI

BackgroundSuboptimal coronary blood flow after primary percutaneous coronary intervention (PCI) is a complex multifactorial phenomenon. Although extensively studied, defined modifiable risk factors and efficient management strategy are lacking. This study aims to determine the potential causes of suboptimal flow and associated impact on 30-day outcomes in patients presenting with anterior ST-elevation myocardial infarction (STEMI).MethodsWe evaluated a total of 1104 consecutive patients admitted to our hospital from January 2016 to December 2018 with the diagnosis of anterior wall STEMI who had primary PCI.ResultsOverall, 245 patients (22.2%) had final post-PCI TIMI flow ≤2 in the LAD (suboptimal flow group) and 859 (77.8%) had final TIMI-3 flow (optimal flow group). The independent predictors of suboptimal flow were thrombus burden grade (Odds ratio (OR) 1.848; p < 0.001), age (OR 1.039 per 1-year increase; p < 0.001), low systolic blood pressure (OR 1.017 per 1 mmHg decrease; p < 0.001), total stent length (OR 1.021 per 1 mm increase; p < 0.001), and baseline TIMI flow ≤1 (OR 1.674; p = 0.018). The 30-day rates of major adverse cardiovascular events (MACE) and cardiac mortality were significantly higher in patients with TIMI flow ≤2 compared to those with TIMI-3 flow (MACE: adjusted risk ratio [RR] 2.021; P = 0.025, cardiac mortality: adjusted RR 2.931; P = 0.031).ConclusionFailure to achieve normal TIMI-3 flow was associated with patient-related (age) and other potentially modifiable risk factors (thrombus burden, admission systolic blood pressure, total stent length, and baseline TIMI flow). The absence of final TIMI-3 flow carried worse short-term clinical outcomes.

CRT-100.36 Predictors of Suboptimal Coronary Blood Flow After Primary Angioplasty and Its Implications on In-Hospital Clinical Outcomes in Patients With Acute Anterior Wall Myocardial Infarction

Suboptimal coronary blood flow after primary percutaneous coronary intervention (PCI) is a multifactorial complex phenomenon. Although extensively studied, defined modifiable risk factors and efficient management strategy are lacking. The aim of this study is to determine the potential causes of

Predictors and prognosis of no-reflow during primary percutaneous coronary intervention

The no-reflow phenomenon occurs in a considerable number of patients with ST elevation myocardial infarction (STEMI) undergoing primary reperfusion therapy. Our study aimed to identify clinical, angiographic, and procedural variables that predict this phenomenon in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI), as well as determine the impact of no-reflow on in-hospital mortality. Prospective observational data from 410 patients with STEMI undergoing PPCI were obtained. In this study, diabetes mellitus, late presentation, higher Killip class at admission, anterior wall infarction, proximal site of occlusion, presence of high-grade thrombus, and left ventricular systolic dysfunction at admission were significantly associated with suboptimal coronary flow. Diabetes mellitus, a high thrombus burden, prolonged total ischemic time, and low left ventricular ejection fraction on admission were independent predictors of no-reflow. No-reflow during PPCI was associated with in-hospital mortality more than twice that for normal flow.

Association Between Intraprocedural Thrombotic Events and Adverse Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction (a Harmonizing Outcomes With RevasculariZatiON and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Substudy)

The present study sought to determine the extent to which adverse angiographic events encountered during percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) are associated with adverse clinical outcomes. Patients with STEMI represent a cohort at particularly high risk of intraprocedural thrombotic events (IPTEs). The overall frequency and implications of IPTEs occurring in patients with STEMI have not been systematically quantified in previous studies. A total of 3,163 patients undergoing primary percutaneous coronary intervention with stent implantation for STEMI in the Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial underwent detailed frame-by-frame core laboratory angiographic analysis to assess IPTEs. The clinical outcomes at 30 days were compared between the patients with and without IPTEs. IPTEs, defined as the development of new or increasing thrombus, abrupt vessel closure, no reflow, slow reflow, and distal embolization at any point during the procedure, occurred in 386 patients (12.2%). The independent predictors of IPTE were thrombus at baseline, lesion length, and randomization to bivalirudin; the patients with IPTEs were also more likely to receive bailout glycoprotein IIb/IIIa inhibitors and unplanned thrombectomy. Compared with patients without IPTEs, the patients with IPTEs had higher 30-day rates of composite major adverse cardiovascular events (death, myocardial infarction, ischemic target vessel revascularization, and stroke; 7.8% vs 4.2%, p = 0.002), major bleeding not related to coronary artery bypass grafting (11.8% vs 6.5%, p <0.001), and all-cause death (4.2% vs 1.8%, p = 0.002). On multivariate analysis, IPTEs were independently associated with 30-day major adverse cardiovascular events, major bleeding, and death. In conclusion, the development of IPTEs in patients undergoing primary percutaneous coronary intervention for STEMI was associated with subsequent adverse outcomes, including major adverse cardiovascular events, major bleeding, and death. Additional studies of strategies to decrease the occurrence of IPTEs are warranted.

Suboptimal coronary blood flow after primary percutaneous coronary intervention for acute myocardial infarction

The aim of the present study is to investigate incidence, predictors, and long-term outcomes of suboptimal coronary flow after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in a large population. A total of 2056 consecutive patients with STEMI (mean age 56.2±11.7 years, 1738 men, 318 women) undergoing primary PCI were retrospectively enrolled in the present study. Patients were grouped as optimal [thrombolysis in myocardial infarction (TIMI) 3 flow, n=1939] and suboptimal (TIMI≤2 flow, n=117) according to the TIMI classification in the infarct-related artery at final coronary angiography after primary PCI, and were followed for in-hospital and long-term outcomes for a mean period of 1.9±1.3 years (median of 22 months). Suboptimal coronary flow was observed in 5.7% (n=117) of the patients. Four variables, selected from the multivariate analysis, were weighted proportionally to their respective odds ratio for suboptimal coronary flow [predilatation before stenting (three points), Killip class 2/3 (two points), glomerular filtration rate<60 ml/min/1.73 m (two points), and anterior myocardial infarction (one point)]. Two strata of risk were defined (low risk, score 0-3; and high risk, score 4-8) and had a strong association with suboptimal coronary flow, and in-hospital and long-term cardiovascular mortalities. The suboptimal group had a higher prevalence of in-hospital mortality compared with the optimal group (22.2 vs. 1.2%, respectively, P<0.001). Long-term cardiovascular mortality was four-fold more in the suboptimal group than the optimal group (15.9 vs 3.7%, respectively, P<0.001). Suboptimal coronary flow after primary PCI in STEMI is strongly related with increased in-hospital and long-term cardiovascular mortalities. Predilatation before stenting is the most powerful predictor of suboptimal coronary flow.

Predictors of nonoptimal coronary flow after primary percutaneous coronary intervention with stent implantation for acute myocardial infarction

Predictors of suboptimal coronary flow in the infarct-related artery (IRA) after stent-based primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) have not been fully investigated. Using the AMI-Kyoto Multi-Center Risk Study database, we retrospectively compared clinical manifestations and in-hospital prognosis between AMI patients undergoing stent-based primary PCI with final Thrombolysis In Myocardial Infarction (TIMI) grade < or = 2 in the IRA (nonoptimal group, n=69) and those with final TIMI grade 3 (optimal group, n=1200). The nonoptimal group had higher prevalence of Killip class > or = 3 at admission, higher frequency of mechanical support devices during procedures, larger value of maximal creatine phosphokinase, and a significantly higher in-hospital mortality rate (27.5% for nonoptimal vs. 9.0% for optimal, P<0.001), compared with the optimal group. On multivariate analysis, Killip class > or = 3 at admission was the independent predictor of the final nonoptimal flow (odds ratio 2.33, 95% confidence intervals 1.27-4.26 P=0.006), but TIMI 3 flow before primary PCI and elapsed time (symptom onset-to-admission time)<24h were not. Killip class > or = 3 at admission is an independent predictor of the final nonoptimal flow in AMI patients undergoing primary PCI with stent implantation.

Duration of Symptoms Is Not Always the Key Modulator of the Choice of Reperfusion for ST-Elevation Myocardial Infarction

Fibrinolytic therapy (FT) and primary percutaneous coronary intervention (PCI) are both well-accepted reperfusion therapies in ST-segment elevation myocardial infarction (STEMI). The evidence of randomized clinical trials indicates a relatively modest difference in 30-day mortality (≈1%) in favor of primary PCI over fibrin-specific FT and was based on very timely primary PCI (ie, a primary PCI–related delay of 40 minutes [door-to-balloon less door-to-needle time]).1 Longer delays to primary PCI, which are far more frequent in clinical practice,2 are associated with attenuated benefit or no benefit at all, particularly when compared with fibrin-specific FT.3,4 The benefit of timely primary PCI over FT is likely to especially apply to higher-risk patients.5,6 Irrespective of the method of reperfusion, the potential for myocardial salvage and better clinical outcome is inversely proportional to ischemic time or its only available clinical surrogate, symptom duration.7–12 These considerations underpin the notion expressed in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of STEMI that timely reperfusion therapy is likely more important in determining outcome than whether FT or primary PCI is the chosen reperfusion method.13 Response by Armstrong et al p 1310 The ACC/AHA STEMI guidelines highlight the time point of 3 hours of symptom duration in guiding the choice of reperfusion therapy. They state that if symptom duration is <3 hours, no preference exists between FT and primary PCI provided that treatment is timely (for FT, door-to-needle time <30 minutes; for primary PCI, door-to-balloon time <90 minutes and ≤60 minutes between estimated needle time and estimated balloon time). However, if symptom duration exceeds 3 hours, these guidelines favor primary PCI over FT, again provided that primary PCI can be performed in a timely fashion.13 This article reexamines the evidence that may or may not be the basis …

Microvascular Obstruction and the No-Reflow Phenomenon After Percutaneous Coronary Intervention

C ase presentation A: A 50-year-old diabetic man presented to the hospital after 8 hours of continuous chest pain. Because of acute myocardial infarction of the anterior wall, he underwent direct stenting to an occlusion in the left anterior descending coronary artery. Despite revascularization, suboptimal coronary flow was achieved, and he subsequently developed heart failure. Case presentation B: A 77-year-old man underwent elective stenting of a significant stenosis in a degenerated saphenous vein coronary bypass graft. After the procedure, coronary flow in the graft was severely reduced, and he sustained a myocardial infarction in the subtended myocardial territory. The concept of “no reflow” refers to a state of myocardial tissue hypoperfusion in the presence of a patent epicardial coronary artery. The underlying cause of no reflow is microvascular obstruction, which may be produced by various mechanisms. No reflow can be classified according to the duration of the preceding myocardial ischemia (Figure 1). “Reperfusion no reflow” occurs after primary percutaneous coronary intervention (PCI) for reperfusion of an infarct artery in the setting of acute myocardial infarction (AMI) and may be asymptomatic or may present clinically with continued chest pain and ST-segment elevation. Reperfusion no reflow is preceded by ischemic cell injury, is confined to the irreversibly damaged necrotic zone, and may be exacerbated at the time of reperfusion. Reperfusion no reflow is an independent predictor of adverse clinical outcome after AMI regardless of infarct size and is associated with heart failure and increased mortality.1 Figure 1. Schematic illustrating the effect of duration of preceding myocardial ischemia on mechanism of no reflow (NR). “Interventional no reflow” follows noninfarct PCI and affects myocardium that was not subjected to prolonged ischemia before the procedure. Clinically recognized interventional no reflow that complicates PCI is typically sudden in onset, presenting as acute ischemia with chest …

Clinical and angiographic correlates and outcomes of suboptimal coronary flow in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

Clinical and angiographic correlates and outcomes of suboptimal coronary flow in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

Clinical and angiographic correlates and outcomes of suboptimal coronary flow inpatients with acute myocardial infarction undergoing primary percutaneous coronary intervention

ObjectivesThe purpose of this study was to determine the clinical and angiographic correlates and outcomes of patients with suboptimal coronary flow after primary percutaneous coronary interventions (PCI). BackgroundThe clinical and angiographic correlates and outcomes of Thrombolysis in Myocardial Infarction (TIMI) ≤2 flow in patients treated with primary PCI are not known. MethodsWe evaluated 3,362 patients with ST elevation myocardial infarction enrolled in various Primary Angioplasty in Myocardial Infarction trials, who underwent primary PCI. ResultsPost-procedural final TIMI ≤2 flow occurred in 232 (6.9%) patients. Multivariate analysis identified age ≥70 years (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1 to 2.2), diabetes (OR 1.9; 95% CI, 1.3 to 2.7), symptom onset to emergency room presentation (OR 1.1; 95% CI, 1.1 to 1.2); initial TIMI ≤1 flow (OR 3.2; 95% CI, 1.9 to 5.5), and left ventricular ejection fraction <50% (OR 1.7; 95% CI, 1.2 to 2.4) as independent correlates of final TIMI ≤2 flow. In-hospital (composite of reinfarction, ischemic target vessel revascularization, or death, as well as these events individually) and one-year (reinfarction and/or death) events occurred more frequently in patients with TIMI ≤2 flow. The Cox proportional hazards model identified TIMI ≤2 flow to be independently associated with one-year mortality (hazard ratio 3.8, 95% CI, 2.5 to 5.7). ConclusionsFinal TIMI ≤2 flow, although uncommon after primary PCI, was strongly associated with hospital and one-year adverse events. The clustering of final TIMI ≤2 flow in high-risk groups may partially explain the poor prognosis of these patients. Awareness of these risk factors may be useful to clinicians to triage and treat patients undergoing primary PCI.

Flow velocity and predictors of a suboptimal coronary flow velocity reserve after coronary balloon angioplasty.

This study was conducted to analyse flow velocity parameters and predictors of a suboptimal coronary flow reserve (<2.5) following balloon angioplasty. Two hundred and twenty-five patients underwent sequential intracoronary Doppler as part of the DEBATE I study. Of these, 183, with complete angiography and Doppler at the 6-month follow-up, were included. Univariate and multivariate logistic analysis was performed to identify independent predictors of post-procedural suboptimal coronary flow reserve, defined as coronary flow reserve <2.5. Forty-eight per cent (n=88) of the patients achieved a suboptimal coronary flow reserve. These patients had higher baseline velocities (cm.s(-1)) before balloon angioplasty (18+/-9 vs 14+/-6, P=0.004), after balloon angioplasty (22+/-11 vs 14+/-5, P<0.001) and at follow-up (19+/-9 vs 16+/-6, P=0.011) than the optimal coronary flow reserve group. Although the suboptimal group had lower hyperaemic velocities (cm.s(-1)) after balloon angioplasty than the optimal group (42+/-17 vs 49+/-16, P=0.008), these velocities became similar at follow-up. Increasing age (odds ratio, OR 1.071, P=0.0002), female gender (OR 2.52, P=0.014) and increasing pre-procedural baseline average peak velocities (OR 1.056, P<0.001) were found to be independent predictors of a suboptimal coronary flow reserve following balloon angioplasty. A suboptimal coronary flow reserve was associated with (1) a chronically elevated baseline average peak velocity (2) a transient deficit in the hyperaemic average peak velocity (3) the elderly, and female gender.