Myocardial Perfusion Grade by Coronary Angiography can Predict Final Infarct Size and Left Ventricular Function in Patients with ST-elevation Myocardial Infarction Treated with a Pharmaco-invasive Strategy

Amal Hafez Ahmed; Amr ELHadidy; Mohamed Helmy; Ashraf Hussein; Abdalla Elagha

doi:10.3889/oamjms.2021.5815

Authors

Amal Hafez Ahmed Department of Critical Care, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
Amr ELHadidy Department of Critical Care, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
Mohamed Helmy Department of Cardiology, National Heart Institute, Cairo University, Cairo, Egypt
Ashraf Hussein Department of Critical Care, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
Abdalla Elagha Department of Cardiology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt

DOI:

https://doi.org/10.3889/oamjms.2021.5815

Keywords:

ST-elevation myocardial infarction, Percutaneous coronary intervention, Myocardial perfusion grade, Infarct size, Perfusion study

Abstract

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the reperfusion strategy of choice in ST-elevation myocardial infarction (STEMI). Transfer for early angioplasty after thrombolytic therapy should be done without delay and has been directly related to improved patients’ outcome compared with thrombolysis alone. TIMI myocardial perfusion (TMP) grade provides important prognostic information for epicardial flow.

AIM: We studied the relationship between TMP grade (at the end of the PCI procedure) and left ventricular ejection fraction (LVEF) and infarct size within 1 month in such patients.

METHODS: A total of forty patients with diagnosis of STEMI (mean age 57.32 ± 10.44, 33 men) were studied, all patients underwent primary PCI. Grading of myocardial perfusion was done immediately post-PCI. Infarction size, end-diastolic volume (EDV), end-systolic volume (ESV), and LVEF were all measured by myocardial perfusion imaging (Gated single-photon emission computed tomography) within 1 month of STEMI.

RESULTS: Final infarct size ranged from 0 to 59 cm (mean =19.18 ± 15.8 cm). EDV ranged from 52 to 228 ml (mean = 128.60 ± 51.01 ml). ESV ranged from 16 to 169 ml (mean =72.05 ± 42.09 ml) and EF ranged from 21% to 72% (mean = 46.0 ± 12.80%). Viable but ischemic myocardial area ranged from 0 to 18 cm (mean =3.38 ± 4.45 cm). There was a significant “negative” correlation between the myocardial perfusion grade and the final infarct size. Furthermore, myocardial perfusion grade was significantly inversely related to EDV and ESV, but directly related to EF. Patients who received thrombolytic therapy had significant lesser perfusion grade than who underwent PCI directly.

CONCLUSION: Assessment of the myocardial perfusion grade during PCI is a good prognostic marker about the final infarct size, ESV, EDV, and EF in patients with STEMI treated with a pharmaco-invasive strategy (thrombolytic followed by PCI).

Downloads

Download data is not yet available.

Metrics

Metrics Loading ...

Plum Analytics Artifact Widget Block

References

Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569-619. PMid:22922416

Borgia F, Goodman SG, Halvorsen S, Cantor WJ, Piscione F, Le May MR, et al. Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST-segment elevation myocardial infarction: A meta-analysis. Eur Heart J. 2010;31(17):2156-69. https://doi.org/10.1093/eurheartj/ehq204 PMid:20601393

Fernandez-Aviles F, Alonso JJ, Pena G, Blanco J, Alonso- Briales J, Lopez-Mesa J, et al. Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: The GRACIA-2 non-inferiority, randomized, controlled trial. Eur Heart J. 2007;28(8):949-60. https://doi.org/10.1093/eurheartj/ehl461 PMid:17244641

Armstrong PW, Gershlick AH, Goldstein P, Wilcox R, Danays T, Lambert Y, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med. 2013;368(15):1379-87. https://doi.org/10.1056/nejmoa1301092 PMid:23473396

Smith SC, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, et al. A report of the American college of cardiology/ American heart association task force on practice guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the society for cardiac angiography and interventions. Circulation. 2001;103(24):3019-41. https://doi.org/10.1161/01.cir.103.24.3019 PMid:11413094

Hoffmann P, Halvorsen S, Stensaeth KH, Brekke M, Muller C, Anker GO, et al. Myocardial perfusion in ST-elevation myocardial infarction treated successfully with primary angioplasty. Scand Cardiovasc J. 2006;40(2):96-104. https://doi.org/10.1080/14017430600628144 PMid:16608779

Stone GW, Peterson MA, Lansky AJ, Dangas G, Mehran R, Leon MB. Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction. J Am Coll Cardiol. 2002;39(4):591-7. https://doi.org/10.1016/s0735-1097(01)01779-x PMid:11849856

Gibson CM, Cannon CP, Murphy SA, Marble SJ, Barron HV, Braunwald E, 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(16):1909-13. https://doi.org/10.1161/01.cir.0000014683.52177.b5 PMid:11997276

Haager PK, Christott P, Heussen N, Lepper W, Hanrath P, Hoffmann R. Prediction of clinical outcome after mechanical revascularization in acute myocardial infarction by markers of myocardial reperfusion. J Am Coll Cardiol. 2003;41(4):532-8. https://doi.org/10.1016/s0735-1097(02)02870-x PMid:12598061

Brener SJ, Cristea E, Mehran R, Dressler O, Lansky AJ, Stone GW. Relationship between angiographic dynamic and densitometric assessment of myocardial reperfusion and survival in patients with acute myocardial infarction treated with primary percutaneous coronary intervention: the harmonizing outcomes with revascularization and stents in AMI (HORIZONS-AMI) trial. Am Heart J. 2011;162(6):1044-51. https://doi.org/10.1016/j.ahj.2011.08.022 PMid:22137078

Brown KA. Prognostic value of thallium-201 myocardial perfusion imaging: A diagnostic tool comes of age. Circulation. 1991;83(2):363-81. https://doi.org/10.1161/01.cir.83.2.363 PMid:1991361

Wackers FJ, Berman DS, Maddahi J, Watson DD, Beller GA, Strauss HW, et al. Technetium-99m-hexakis 2 methoxyisobutyl isonitrile: Human biodistribution, dosimetry, safety, and preliminary comparison to thallium-201 for myocardial perfusion imaging. J Nucl Med. 1989;30(3):301-11. PMid:2525610

De Boer MJ, Suryapranata H, Hoorntje JC, Reiffers S, Liem AL, Miedema K, et al. Limitation of infarct size and preservation of left ventricular function after primary coronary angioplasty compared with intravenous streptokinase in acute myocardial infarction. Circulation. 1994;90(2):753-61. https://doi.org/10.1161/01.cir.90.2.753 PMid:8044944

Pride YB, Buros JL, Lord E, Southard M., Harrigan CJ, Ciaglo L. Angiographic perfusion score in patients treated with PCI at late angiography following fibrinolytic administration for ST-segment elevation myocardial infarction is associated with morbidity and mortality at 30 days. J Thromb Thrombolysis. 2008;26(2):106- 12. https://doi.org/10.1007/s11239-007-0075-z PMid:17624497

Bethke A1, Halvorsen S, Bøhmer E, Abdelnoor M, Arnesen H, Hoffmann P. Myocardial perfusion grade predicts final infarct size and left ventricular function in patients with ST-elevation myocardial infarction treated with a pharmaco-invasive strategy (thrombolysis and early angioplasty). Eurointervention. 2015;11(5):518-24. https://doi.org/10.4244/eijy15m04_02 PMid:25868877

Wong DT, Leung MC, Richardson JD, Puri R, Bertaso AG, Williams K, et al. Cardiac magnetic resonance derived late microvascular obstruction assessment post ST-segment elevation myocardial infarction is the best predictor of left ventricular function: A comparison of angiographic and cardiac magnetic resonance derived measurements. Int J Cardiovasc Imaging. 2012;28(8):1971-81. https://doi.org/10.1007/s10554-012-0021-9 PMid:22310980

De Luca G, Van’t Hof AW, De Boer MJ, Hoorntje JC, Gosselink AT, Dambrink JH, et al. Impaired myocardial perfusion is a major explanation of the poor outcome observed in patients undergoing primary angioplasty for ST-segment-elevation myocardial infarction and signs of heart failure. Circulation. 2004;109(8):958- 61. https://doi.org/10.1161/01.cir.0000120504.31457.28 PMid:14981008

Berk F, Isgoren S, Demir H, Kozdag G, Sahin T, Ural D, et al. Assessment of left ventricular function and volumes for patients with dilated cardiomyopathy using gated myocardial perfusion SPECT and comparison with echocardiography. Nucl Med Commun. 2005;26(8):701-10. https://doi.org/10.1097/01.mnm.0000170938.98581.14 PMid:16000988

Schaefer WM, Lipke CS, Standke D, Kühl HP, Nowak B, Kaiser HJ, et al. Quantification of left ventricular volumes and ejection fraction from gated 99mTc-MIBI SPECT: MRI validation and comparison of the emory cardiac tool box with QGS and 4D-MSPEC. J Nucl Med. 2005;46(8):1256-63. https://doi.org/10.1007/s00259-006-0322-0 PMid:16085580

Gai JJ, Gai LY, Yan JJ, Jin QH. Calculation of coronary angiographic total blush in patients with coronary artery disease and its prognostic implication. Chin Med J (Engl) 2015;128(18):2485- 90. https://doi.org/10.4103/0366-6999.164934 PMid:26365967

Van’t Hof AW, Liem A, Suryapranata H, Hoorntje JC, De Boer MJ, Zijlstra F. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: myocardial blush grade. Zwolle Myocardial Infarction Study Group. Circulation. 1998;97:2302- 6. https://doi.org/10.1161/01.cir.97.23.2302 PMid:9639373

Appelbaum E, Kirtane AJ, Clark A, Pride YB, Gelfand EV, Harrigan CJ, et al. Association of TIMI myocardial perfusion grade and ST-segment resolution with cardiovascular magnetic resonance measures of microvascular obstruction and infarct size following ST-segment elevation myocardial infarction. J Thromb Thrombolysis. 2009;27(2):123-9. https://doi.org/10.1007/s11239-008-0197-y PMid:18246410

Svensson L, Aasa M, Dellborg M, Gibson CM, Kirtane A, Herlitz J, et al. Comparison of very early treatment with either fibrinolysis or percutaneous coronary intervention facilitated with abciximab with respect to ST recovery and infarct-related artery epicardial flow in patients with acute ST-segment elevation myocardial infarction: The Swedish Early Decision (SWEDES) reperfusion trial. Am Heart J. 2006;151(4):798.e1-7. https://doi.org/10.1016/j.ahj.2005.09.013 PMid:16569536

Sutton AG, Campbell PG, Price DJ, Grech ED, Hall JA, Davies A, et al. Failure of thrombolysis by streptokinase: Detection with a simple electrocardiographic method. Heart. 2000;84(2):149- 56. https://doi.org/10.1136/heart.84.2.149 PMid:10908249

Rahuman F, Jayawardena JB, Francis GR, Mahboob N, Kumara AH, Wijesinghe A, et al. A comparison of rescue and primary percutaneous coronary interventions for acute ST elevation myocardial infarction. Indian Heart J. 2017;69(Suppl 1):S57-62. https://doi.org/10.1016/j.ihj.2017.02.019 PMid:28400040

Collet JP, Montalescot G, Le May M, Borentain M, Gershlick A. Percutaneous coronary intervention after fibrinolysis: A multiple meta-analyses approach according to the type of strategy. J Am Coll Cardiol. 2006;48(7):1326-35. https://doi.org/10.1016/j.jacc.2006.03.064 PMid:17010790