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(Circulation. 2000;101:125.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Relationship of TIMI Myocardial Perfusion Grade to Mortality After Administration of Thrombolytic Drugs
From the Cardiovascular Divisions of the Departments of Medicine, the University of California at San Francisco, San Francisco (C.M.G., S.A.M., K.A.R., R.M., S.J.M.), University Hospitals Leuven, Leuven, Belgium (F.V.d.W.), and Brigham & Women’s Hospital, Boston, Mass (C.P.C., C.H.M., E.B.).
Background—Although improved epicardial blood flow (as assessed with either TIMI flow grades or TIMI frame count) has been related to reduced mortality after administration of thrombolytic drugs, the relationship of myocardial perfusion (as assessed on the coronary arteriogram) to mortality has not been examined.
Methods and Results—A new, simple angiographic method, the TIMI myocardial perfusion (TMP) grade, was used to assess the filling and clearance of contrast in the myocardium in 762 patients in the TIMI (Thrombolysis In Myocardial Infarction) 10B trial, and its relationship to mortality was examined. TMP grade 0 was defined as no apparent tissue-level perfusion (no ground-glass appearance of blush or opacification of the myocardium) in the distribution of the culprit artery; TMP grade 1 indicates presence of myocardial blush but no clearance from the microvasculature (blush or a stain was present on the next injection); TMP grade 2 blush clears slowly (blush is strongly persistent and diminishes minimally or not at all during 3 cardiac cycles of the washout phase); and TMP grade 3 indicates that blush begins to clear during washout (blush is minimally persistent after 3 cardiac cycles of washout). There was a mortality gradient across the TMP grades, with mortality lowest in those patients with TMP grade 3 (2.0%), intermediate in TMP grade 2 (4.4%), and highest in TMP grades 0 and 1 (6.0%; 3-way P=0.05). Even among patients with TIMI grade 3 flow in the epicardial artery, the TMP grades allowed further risk stratification of 30-day mortality: 0.73% for TMP grade 3; 2.9% for TMP grade 2; 5.0% for TMP grade 0 or 1 (P=0.03 for TMP grade 3 versus grades 0, 1, and 2; 3-way P=0.066). TMP grade 3 flow was a multivariate correlate of 30-day mortality (OR 0.35, 95% CI 0.12 to 1.02, P=0.054) in a multivariate model that adjusted for the presence of TIMI 3 flow (P=NS), the corrected TIMI frame count (OR 1.02, P=0.06), the presence of an anterior myocardial infarction (OR 2.3, P=0.03), pulse rate on admission (P=NS), female sex (P=NS), and age (OR 1.1, P<0.001).
Conclusions—Impaired perfusion of the myocardium on coronary arteriography by use of the TMP grade is related to a higher risk of mortality after administration of thrombolytic drugs that is independent of flow in the epicardial artery. Patients with both normal epicardial flow (TIMI grade 3 flow) and normal tissue level perfusion (TMP grade 3) have an extremely low risk of mortality.
Key Words: mortality • risk factors • perfusion • thrombolysis
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H. C. Herrmann Optimizing outcomes in ST-segment elevation myocardial infarction J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1357 - 1359. [Full Text] [PDF]
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G. Dangas Interventional therapy for acute myocardial infarction: respect the microvasculature J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1403 - 1405. [Full Text] [PDF]
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R Hoffmann, P Haager, W Lepper, A Franke, and P Hanrath Relation of coronary flow pattern to myocardial blush grade in patients with first acute myocardial infarction Heart, October 1, 2003; 89(10): 1147 - 1151. [Abstract] [Full Text] [PDF]
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B. Scheller, B. Hennen, B. Hammer, J. Walle, C. Hofer, V. Hilpert, H. Winter, G. Nickenig, M. Bohm, and SIAM III Study Group Beneficial effects of immediate stenting after thrombolysis in acute myocardial infarction J. Am. Coll. Cardiol., August 20, 2003; 42(4): 634 - 641. [Abstract] [Full Text] [PDF]
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C. M. Gibson Has My Patient Achieved Adequate Myocardial Reperfusion? Circulation, August 5, 2003; 108(5): 504 - 507. [Full Text] [PDF]
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G. Cotter, E. Kaluski, O. Milo, A. Blatt, A. Salah, A. Hendler, R. Krakover, A. Golick, and Z. Vered LINCS: L-NAME (a NO synthase inhibitor) In the treatment of refractory Cardiogenic Shock: A prospective randomized study Eur. Heart J., July 2, 2003; 24(14): 1287 - 1295. [Abstract] [Full Text] [PDF]
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W. F. Fearon, L. B. Balsam, H. M. O. Farouque, R. C. Robbins, P. J. Fitzgerald, P. G. Yock, and A. C. Yeung Novel Index for Invasively Assessing the Coronary Microcirculation Circulation, July 1, 2003; 107(25): 3129 - 3132. [Abstract] [Full Text] [PDF]
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J. P.S. Henriques, F. Zijlstra, A. W.J. van 't Hof, M.-J. de Boer, J.-H. E. Dambrink, M. Gosselink, J. C.A. Hoorntje, and H. Suryapranata Angiographic Assessment of Reperfusion in Acute Myocardial Infarction by Myocardial Blush Grade Circulation, April 29, 2003; 107(16): 2115 - 2119. [Abstract] [Full Text] [PDF]
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R. P. Giugliano, M. T. Roe, R. A. Harrington, C. M. Gibson, U. Zeymer, F. Van de Werf, K. W. Baran, H.-P. Hobbach, L. H. Woodlief, K. L. Hannan, et al. Combination reperfusion therapy with eptifibatide and reduced-dose tenecteplase for ST-elevation myocardial infarction: Results of the integrilin and tenecteplase in acute myocardial infarction (INTEGRITI) Phase II Angiographic urial J. Am. Coll. Cardiol., April 16, 2003; 41(8): 1251 - 1260. [Abstract] [Full Text] [PDF]
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D V Cokkinos, A Manginas, and V Voudris Coronary flow: clinical considerations Heart, April 1, 2003; 89(4): 361 - 363. [Full Text] [PDF]
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D. P. Lee, N. A. Herity, B. L. Hiatt, W. F. Fearon, M. Rezaee, A. J. Carter, M. Huston, D. Schreiber, P. M. DiBattiste, and A. C. Yeung Adjunctive Platelet Glycoprotein IIb/IIIa Receptor Inhibition With Tirofiban Before Primary Angioplasty Improves Angiographic Outcomes: Results of the TIrofiban Given in the Emergency Room before Primary Angioplasty (TIGER-PA) Pilot Trial Circulation, March 25, 2003; 107(11): 1497 - 1501. [Abstract] [Full Text] [PDF]
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A. Dibra, J. Mehilli, J. Dirschinger, J.u. Pache, J. Neverve, M. Schwaiger, A. Schomig, and A. Kastrati Thrombolysis in myocardial infarction myocardial perfusion grade in angiography correlates with myocardial salvage in patients with acute myocardial infarction treated with stenting or thrombolysis J. Am. Coll. Cardiol., March 19, 2003; 41(6): 925 - 929. [Abstract] [Full Text] [PDF]
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P. K. Haager, P. Christott, N. Heussen, W. Lepper, P. Hanrath, and R. Hoffmann Prediction of clinical outcome after mechanical revascularization in acute myocardial infarction by markers of myocardial reperfusion J. Am. Coll. Cardiol., February 19, 2003; 41(4): 532 - 538. [Abstract] [Full Text] [PDF]
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M. S. Sabatine, D. A. Morrow, C. P. Cannon, S. A. Murphy, L. A. Demopoulos, P. M. DiBattiste, C. H. McCabe, E. Braunwald, and C. M. Gibson Relationship between baseline white blood cell count and degree of coronary artery disease and mortality in patients with acute coronary syndromes: A TACTICS-TIMI 18 substudy J. Am. Coll. Cardiol., November 20, 2002; 40(10): 1761 - 1768. [Abstract] [Full Text] [PDF]
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F.-J. Neumann and N. Jander How to best counteract the enemies? By ensuring adequate oxygen delivery Eur. Heart J. Suppl., November 1, 2002; 4(suppl_G): G35 - G42. [Abstract] [PDF]
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D. P. Faxon, R. J. Gibbons, N. A. F. Chronos, P. A. Gurbel, F. Sheehan, and HALT-MI Investigators The effect of blockade of the CD11/CD18 integrin receptor on infarct size in patients with acute myocardial infarction treated with direct angioplasty: the results of the HALT-MI study J. Am. Coll. Cardiol., October 2, 2002; 40(7): 1199 - 1204. [Abstract] [Full Text] [PDF]
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C.-K. Wong, J.K. French, M.W. Krucoff, W. Gao, P.E. Aylward, and H.D. White Slowed ST segment recovery despite early infarct artery patency in patients with Q waves at presentation with a first acute myocardial infarction. Implications of initial Q waves on myocyte reperfusion Eur. Heart J., September 2, 2002; 23(18): 1449 - 1455. [Abstract] [Full Text] [PDF]
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T. R. Bowers, W. W. O'Neill, M. Pica, and J. A. Goldstein Patterns of Coronary Compromise Resulting in Acute Right Ventricular Ischemic Dysfunction Circulation, August 27, 2002; 106(9): 1104 - 1109. [Abstract] [Full Text] [PDF]
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A. Poli, R. Fetiveau, P. Vandoni, G. del Rosso, M. D'Urbano, G. Seveso, F. Cafiero, and S. De Servi Integrated Analysis of Myocardial Blush and ST-Segment Elevation Recovery After Successful Primary Angioplasty: Real-Time Grading of Microvascular Reperfusion and Prediction of Early and Late Recovery of Left Ventricular Function Circulation, July 16, 2002; 106(3): 313 - 318. [Abstract] [Full Text] [PDF]
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G. C. Wong, D. A. Morrow, S. Murphy, N. Kraimer, R. Pai, D. James, D. H. Robertson, L. A. Demopoulos, P. DiBattiste, C. P. Cannon, et al. Elevations in Troponin T and I Are Associated With Abnormal Tissue Level Perfusion: A TACTICS-TIMI 18 Substudy Circulation, July 9, 2002; 106(2): 202 - 207. [Abstract] [Full Text] [PDF]
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J.P.S. Henriques, F. Zijlstra, J.P. Ottervanger, M.-J. de Boer, A.W.J. van 't Hof, J.C.A. Hoorntje, and H. Suryapranata Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction Eur. Heart J., July 2, 2002; 23(14): 1112 - 1117. [Abstract] [Full Text] [PDF]
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S. Allaqaband and T. K. Bajwa "Time Is Muscle" Only in Experienced Hands and High-Volume Centers J Intensive Care Med, July 1, 2002; 17(4): 199 - 201. [PDF]
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M. Aschermann and P. Widimsky I have an acute myocardial infarction: open my coronary artery, stent it and keep full flow! Eur. Heart J., June 2, 2002; 23(12): 913 - 916. [Full Text] [PDF]
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P Andrassy, M Zielinska, R Busch, A Schomig, and C Firschke Myocardial blood volume and the amount of viable myocardium early after mechanical reperfusion of acute myocardial infarction: prospective study using venous contrast echocardiography Heart, April 1, 2002; 87(4): 350 - 355. [Abstract] [Full Text] [PDF]
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G. W. Stone, M. A. Peterson, A. J. Lansky, G. Dangas, R. Mehran, and M. B. Leon Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction J. Am. Coll. Cardiol., February 20, 2002; 39(4): 591 - 597. [Abstract] [Full Text] [PDF]
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B. G. Angeja, M. Gunda, S. A. Murphy, B. E. Sobel, A. C. Rundle, M. Syed, A. Asfour, S. Borzak, S. G. Gourlay, H. V. Barron, et al. TIMI Myocardial Perfusion Grade and ST Segment Resolution: Association With Infarct Size as Assessed by Single Photon Emission Computed Tomography Imaging Circulation, January 22, 2002; 105(3): 282 - 285. [Abstract] [Full Text] [PDF]
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K. W. Baran, M. Nguyen, G. R. McKendall, C. T. Lambrew, G. Dykstra, S. T. Palmeri, R. J. Gibbons, S. Borzak, B. E. Sobel, S. G. Gourlay, et al. Double-Blind, Randomized Trial of an Anti-CD18 Antibody in Conjunction With Recombinant Tissue Plasminogen Activator for Acute Myocardial Infarction: Limitation of Myocardial Infarction Following Thrombolysis in Acute Myocardial Infarction (LIMIT AMI) Study Circulation, December 4, 2001; 104(23): 2778 - 2783. [Abstract] [Full Text] [PDF]
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J. A. de Lemos and E. Braunwald ST segment resolution as a tool for assessing the efficacy of reperfusion therapy J. Am. Coll. Cardiol., November 1, 2001; 38(5): 1283 - 1294. [Abstract] [Full Text] [PDF]
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