Target vessel reopening by guidewire insertion in ST-elevation myocardial infarction is a predictor of final TIMI flow and survival

Summary

ST-elevation myocardial infarction (STEMI) results from acute thrombotic obstruction of a coronary artery. Percutaneous coronary intervention (PCI) is the treatment of choice to restore blood flow. The incidence of guidewire-induced reopening of the infarct-related coronary artery (IRA) and its association with post-procedural TIMI flow and long-term mortality were assessed. Angiograms of consecutive STEMI patients admitted to the catheter laboratory of the Medical University of Vienna between January 2003 and December 2005 were analysed. TIMI flow was graded prior to and after guidewire insertion into the distality of the IRA, and at the end of the procedure. Initial TIMI 0 flow was present in 476 (47.0%) of 1,012 cases. Target vessel reopening after guidewire insertion defined as any flow >TIMI 0 flow occurred in 150 patients (37.2%), and was associated with improved survival after a median of 914 (609–1,238) days (p=0.017). Reflow after guidewire insertion was an independent predictor of post-procedural TIMI flow (odds ratio=3.10, 95% confidence interval [CI]=1.64 – 5.86], p<0.001) and mortality (hazard ratio=0.51, CI=0.28 – 0.94], p=0.029). Target vessel reopening by guidewire insertion is a new predictor of prognosis. Target vessel flow after guidewire insertion should be assessed in a standardised fashion during PCI.

Keywords

Myocardial infarction - prognosis - thrombectomy - guidewire - reper-fusion

• References

• 1 Thatcher JL. et al. Improved efficiency in acute myocardial infarction care through commitment to emergency department-initiated primary PCI. J Invasive Cardiol 2003; 15: 693-698.
• 2 Van de Werf F. et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology. Eur Heart J 2008; 29: 2909-2945.
• 3 Gibson CM. et al. Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction. Circulation 2002; 105: 1909-1913.
• 4 Sabatine MS. et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 2005; 352: 1179-1189.
• 5 Brodie BR. et al. Benefit of coronary reperfusion before intervention on outcomes after primary angioplasty for acute myocardial infarction. Am J Cardiol 2000; 85: 13-18.
• 6 van’t Hof AW. et al. Facilitation of primary coronary angioplasty by early start of a glycoprotein 2b/3a inhibitor: results of the ongoing tirofiban in myocardial infarction evaluation (On-TIME) trial. Eur Heart J 2004; 25: 837-846.
• 7 Kurowski V. et al. The effects of facilitated primary PCI by guide wire on procedural and clinical outcomes in acute ST-segment elevation myocardial infarction. Clin Res Cardiol 2007; 96: 557-565.
• 8 Chesebro JH. et al. Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation 1987; 76: 142-154.
• 9 Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958; 53: 457-481.
• 10 Cox D. Regression models and life tables. JR Stat Soc B 1972; 34: 187-220.
• 11 Lev EI. et al. Effect of clopidogrel pretreatment on angiographic and clinical outcomes in patients undergoing primary percutaneous coronary intervention for ST-elevation acute myocardial infarction. Am J Cardiol 2008; 101: 435-439.
• 12 Adlbrecht C. et al. Active endothelin is an important vasoconstrictor in acute coronary thrombi. Thromb Haemost 2007; 97: 642-649.
• 13 Distelmaier K. et al. Local complement activation triggers neutrophil recruitment to the site of thrombus formation in acute myocardial infarction. Thromb Haemost 2009; 102: 564-572.
• 14 Perrin J. et al. In vitro effects of human neutrophil cathepsin G on thrombin generation: Both acceleration and decreased potential. Thromb Haemost 2010; 104: 514-522.
• 15 Bonderman D. et al. Role for staphylococci in misguided thrombus resolution of chronic thromboembolic pulmonary hypertension. Arterioscl Thromb Vasc Biol 2008; 28: 678-684.
• 16 Bernlochner I. et al. Association between inflammatory biomarkers and platelet aggregation in patients under chronic clopidogrel treatment. Thromb Haemost 2010; 104: 1193-1200.
• 17 Kramer MC. et al. Presence of older thrombus is an independent predictor of long-term mortality in patients with ST-elevation myocardial infarction treated with thrombus aspiration during primary percutaneous coronary intervention. Circulation 2008; 118: 1810-1816.
• 18 Hausenloy DJ. Signalling pathways in ischaemic postconditioning. Thromb Haemost 2009; 101: 626-634.
• 19 Stone GW. et al. Normal flow (TIMI-3) before mechanical reperfusion therapy is an independent determinant of survival in acute myocardial infarction: analysis from the primary angioplasty in myocardial infarction trials. Circulation 2001; 104: 636-641.
• 20 De Luca G. et al. Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty. J Am Coll Cardiol 2003; 42: 991-997.
• 21 Bates E. et al. Intracoronary KAI-9803 as an adjunct to primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction. Circulation 2008; 117: 886-896.
• 22 Nakatani D. et al. Effect of intracoronary thrombectomy on 30-day mortality in patients with acute myocardial infarction. Am J Cardiol 2007; 100: 1212-1217.
• 23 Maioli M. et al. Randomized early versus late abciximab in acute myocardial infarction treated with primary coronary intervention (RELAx-AMI Trial). J Am Coll Cardiol 2007; 49: 1517-1524.
• 24 Ellis SG. et al. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med 2008; 358: 2205-2217.
• 25 Cannon CP. Importance of TIMI 3 flow. Circulation 2001; 104: 624-626.
• 26 Beran G. et al. Intracoronary thrombectomy with the X-sizer catheter system improves epicardial flow and accelerates ST-segment resolution in patients with acute coronary syndrome: a prospective, randomized, controlled study. Circulation 2002; 105: 2355-2360.