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Circulation. 2000;101:125-130

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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

C. Michael Gibson, MS, MD; Christopher P. Cannon, MD; Sabina A. Murphy, MPH; Kathryn A. Ryan, BS; Rebecca Mesley, BS; Susan J. Marble, RN, MS; Carolyn H. McCabe, BS; Frans Van de Werf, MD, PhD; Eugene Braunwald, MD; for the TIMI (Thrombolysis In Myocardial Infarction) Study Group

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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J. Am. Coll. Cardiol., July 21, 2004; 44(2): 313 - 315.
[Full Text] [PDF]


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CirculationHome page
C. M. Gibson and A. Schomig
Coronary and Myocardial Angiography: Angiographic Assessment of Both Epicardial and Myocardial Perfusion
Circulation, June 29, 2004; 109(25): 3096 - 3105.
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BMJHome page
D. Smith
Primary angioplasty should be first line treatment for acute myocardial infarction: FOR
BMJ, May 22, 2004; 328(7450): 1254 - 1256.
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J Am Coll CardiolHome page
C. M. Gibson, J. Karha, S. A. Murphy, J. A. de Lemos, D. A. Morrow, R. P. Giugliano, M. T. Roe, R. A. Harrington, C. P. Cannon, E. M. Antman, et al.
Association of a pulsatile blood flow pattern on coronary arteriography and short-term clinical outcomes in acute myocardial infarction
J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1170 - 1176.
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J Am Coll CardiolHome page
C. M. Gibson, D. S. Pinto, S. A. Murphy, D. A. Morrow, H.-P. Hobbach, S. D. Wiviott, R. P. Giugliano, C. P. Cannon, E. M. Antman, E. Braunwald, et al.
Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality
J. Am. Coll. Cardiol., November 5, 2003; 42(9): 1535 - 1543.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
H. C. Herrmann
Optimizing outcomes in ST-segment elevation myocardial infarction
J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1357 - 1359.
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J Am Coll CardiolHome page
G. Dangas
Interventional therapy for acute myocardial infarction: respect the microvasculature
J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1403 - 1405.
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HeartHome page
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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J Am Coll CardiolHome page
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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CirculationHome page
C. M. Gibson
Has My Patient Achieved Adequate Myocardial Reperfusion?
Circulation, August 5, 2003; 108(5): 504 - 507.
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Eur Heart JHome page
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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CirculationHome page
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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Arch Intern MedHome page
P. Pruszczyk, M. Szulc, G. Horszczaruk, H. Gurba, and M. Kobylecka
Right Ventricular Infarction in a Patient With Acute Pulmonary Embolism and Normal Coronary Arteries
Arch Intern Med, May 12, 2003; 163(9): 1110 - 1111.
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CirculationHome page
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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J Am Coll CardiolHome page
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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HeartHome page
D V Cokkinos, A Manginas, and V Voudris
Coronary flow: clinical considerations
Heart, April 1, 2003; 89(4): 361 - 363.
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CirculationHome page
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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J Am Coll CardiolHome page
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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J Am Coll CardiolHome page
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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Cardiovasc ResHome page
E. Braunwald
Personal reflections on efforts to reduce ischemic myocardial damage
Cardiovasc Res, December 1, 2002; 56(3): 332 - 338.
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J Am Coll CardiolHome page
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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Eur Heart J SupplHome page
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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J Am Coll CardiolHome page
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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Eur Heart JHome page
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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CirculationHome page
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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CirculationHome page
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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CirculationHome page
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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Eur Heart JHome page
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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J Intensive Care MedHome page
N. J. Goswami, J. M. Moody Jr, and S. R. Bailey
Percutaneous Mechanical Reperfusion During Acute Myocardial Infarction
J Intensive Care Med, July 1, 2002; 17(4): 162 - 173.
[Abstract] [PDF]


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J Intensive Care MedHome page
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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Eur Heart JHome page
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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BloodHome page
D. Bonderman, A. Teml, J. Jakowitsch, C. Adlbrecht, M. Gyongyosi, W. Sperker, H. Lass, W. Mosgoeller, D. H. Glogar, P. Probst, et al.
Coronary no-reflow is caused by shedding of active tissue factor from dissected atherosclerotic plaque
Blood, April 15, 2002; 99(8): 2794 - 2800.
[Abstract] [Full Text] [PDF]


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HeartHome page
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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J Am Coll CardiolHome page
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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CirculationHome page
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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CirculationHome page
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 Am Coll CardiolHome page
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]