Circulation, Vol 86, 81-90, Copyright © 1992 by American Heart Association
TF Christian, RS Schwartz and RJ Gibbons
BACKGROUND. Experimental animal studies have demonstrated that myocardium
at risk, residual collateral flow, and duration of coronary artery
occlusion are important determinants of final infarct size. The present
study examined these variables in patients with acute myocardial infarction
in relation to final infarct size. METHODS AND RESULTS. Myocardium at risk
was assessed with hexakis(2-methoxyisobutyl isonitrile) technetium (I)
(99mTc sestamibi) in 89 patients with first- time myocardial infarction
(anterior, 48 patients; inferior, 41 patients). All patients had successful
reperfusion therapy with either intravenous thrombolysis (32 patients) or
primary coronary angioplasty (57 patients) within 24 hours of the onset of
chest pain (4.7 +/- 3.9 hours; range, 0.5-21.5 hours) documented by
coronary angiography. 99mTc sestamibi was injected intravenously before
reperfusion therapy, and tomographic imaging was performed 1-6 hours later.
Myocardium at risk was quantitated for each patient and expressed as a
percentage of the left ventricle: 35 +/- 19%; range, 2-73%. Collateral flow
was estimated by both invasive and noninvasive methods. Fifty-three
patients with TIMI grade 0 or I flow who underwent primary coronary
angioplasty had collateral flow graded angiographically (0-3) before the
first balloon inflation. All patients had collateral flow estimated
noninvasively from the acute sestamibi short-axis profile curve by three
methods that assess the severity of the perfusion defect. Each of these
three methods was significantly associated with angiographic collateral
grade. Final infarct size was determined at hospital discharge by a second
sestamibi study (17 +/- 17%; range, 0-59%). Myocardium at risk (r = 0.61, p
less than 0.0001), angiographic collateral grade (p = 0.0003), and
radionuclide estimates of collateral flow (r = 0.69-0.70, all p less than
0.0001) were all significantly associated with final infarct size. The time
to reperfusion therapy was not significantly associated with final infarct
size by univariate analysis (r = 0.18, p = 0.10). Two multivariate models
were constructed to determine which variables were independently associated
with final infarct size. In the invasive model, myocardium at risk,
angiographic collateral grade with an interaction term for infarct
location, and time to reperfusion were all independently significant and
accounted for 70% of the variability in final infarct size. The noninvasive
model, which substituted a radionuclide estimate of collateral flow for
angiographic collateral grade, showed nearly identical results, accounting
for 68% of the variability in infarct size in patients where the infarct
artery was known to be occluded. When all patients were included (patients
with and without acute angiography), the noninvasive model accounted for
59% of the variability in infarct size. CONCLUSIONS. Myocardium at risk,
collateral flow, and duration of coronary occlusion are each independently
associated with final infarct size and account for most of its variability.
Ideally, all three parameters should be examined in evaluation of the
efficacy of new treatment strategies for acute myocardial infarction.
ARTICLES
Determinants of infarct size in reperfusion therapy for acute myocardial infarction
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minn 55905.
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