Combined assessment of thrombolysis in myocardial infarction flow grade, myocardial perfusion grade, and ST-segment resolution to evaluate epicardial and myocardial reperfusion.
The restoration of epicardial and myocardial flow remains the primary goal of reperfusion therapy in patients with ST-segment elevation myocardial infarction, but the optimal method to assess this goal has not been defined. Thrombolysis In Myocardial Infarction flow grade (TFG), myocardial perfusion grade (MPG), and ST-segment resolution (STRes) were combined to formulate a new measure of successful reperfusion in 649 patients who received pharmacologic reperfusion therapy in 3 recent phase II clinical trials of ST-segment elevation myocardial infarction. Coronary angiograms and electrocardiograms were analyzed at 60 minutes (before any intervention) after the initiation of reperfusion therapy. The complete restoration of perfusion, or the "trifecta," defined as the presence of TFG 3, MPG 3, and complete (> or =70%) STRes, occurred in 117 patients (18%). The achievement of this trifecta was associated with low rates of 30-day mortality (0% vs 3.9%, p = 0.02), congestive heart failure (CHF) (0.9% vs 7.1%, p = 0.01), and the combination of death or CHF (0.9% vs 10.7%, p = 0.001). When the results were stratified with respect to subsequent percutaneous coronary intervention (PCI) from 60 to 120 minutes, attainment of the trifecta at 60 minutes remained a strong predictor of better clinical outcomes, particularly in those patients who underwent early PCI. The achievement of TFG 3, MPG 3, and complete STRes at 60 minutes after fibrinolytic therapy and before PCI occurred in only 18% of patients but was associated with very low rates of death and CHF at 30 days. This new end point is proposed to evaluate the success of reperfusion therapy in patients who undergo early angiography.
Giugliano
Robert P
RP
TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115, USA. rgiugliano@partners.org
Sabatine
Marc S
MS
Gibson
C Michael
CM
Roe
Matthew T
MT
Harrington
Robert A
RA
Murphy
Sabina A
SA
Morrow
David A
DA
Antman
Elliott M
EM
Braunwald
Eugene
E
D000077284:Abciximab; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D017322:Clinical Trials, Phase II as Topic; D015331:Cohort Studies; D017023:Coronary Angiography; D004562:Electrocardiography; D017984:Enoxaparin / Q000627:therapeutic use; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D015425:Myocardial Reperfusion; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D000077785:Tenecteplase; D015912:Thrombolytic Therapy; D013997:Time Factors; D000077466:Tirofiban; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014443:Tyrosine / Q000031:analogs & derivatives* / Q000627:therapeutic use
D000911:Antibodies, Monoclonal; D017984:Enoxaparin; D005343:Fibrinolytic Agents; D007140:Immunoglobulin Fab Fragments; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D014443:Tyrosine; D010959:Tissue Plasminogen Activator; D000077466:Tirofiban; D000077785:Tenecteplase; D000077284:Abciximab