The TIMI ST-elevation myocardial infarction (STEMI) score was developed and validated in a randomized controlled trial population. We sought to assess its accuracy in a community-based cohort of elderly patients hospitalized with STEMI.
We evaluated the TIMI STEMI score in 47882 patients aged ≥65 years hospitalized with STEMI in US hospitals from 1994 to 1996. We assessed TIMI STEMI score discrimination and calibration for 30-day mortality and compared observed and published TIMI mortality rates.
The cohort’s median TIMI score was 6 (25th–75th percentile 4, 8). Thirty-day mortality rates were higher among patients with higher TIMI scores (TIMI score 2: 4.4% vs TIMI score >8: 35.6%, P < .0001 for trend). However, the TIMI score provided only modest discrimination (c = 0.67) and calibration (goodness-of-fit P < .0001). Mortality rates for TIMI scores differed between patients who did and did not receive reperfusion therapy (P < .0001 for TIMI score × reperfusion therapy interaction). Thirty-day mortality rates in the cohort were higher than published TIMI estimates (P = .001; eg, TIMI score 2: 4.4% cohort vs 2.2% published rate).
The TIMI score provided modest prognostic discrimination and calibration among elderly patients with STEMI. Our findings highlight the difficulties in applying risk scores developed in randomized controlled trial cohorts to elderly patients.
The Thrombolysis in Myocardial Infarction (TIMI) risk scores for Unstable Angina/Non-ST–elevation myocardial infarction (UA/NSTEMI) and ST-elevation myocardial infarction (STEMI) and the Global Registry of Acute Coronary Events (GRACE) risk scores for in-hospital and 6-month mortality are established tools for assessing risk in Acute Coronary Syndrome (ACS) patients. The objective of our study was to compare the discriminative abilities of the TIMI and GRACE risk scores in a broad-spectrum, unselected ACS population and to assess the relative contributions of model simplicity and model composition to any observed differences between the two scoring systems.
ACS patients admitted to the University of Michigan between 1999 and 2005 were divided into UA/NSTEMI (n = 2753) and STEMI (n = 698) subpopulations. The predictive abilities of the TIMI and GRACE scores for in-hospital and 6-month mortality were assessed by calibration and discrimination. There were 137 in-hospital deaths (4%), and among the survivors, 234 (7.4%) died by 6 months post-discharge. In the UA/NSTEMI population, the GRACE risk scores demonstrated better discrimination than the TIMI UA/NSTEMI score for in-hospital (C = 0.85, 95% CI: 0.81–0.89, versus 0.54, 95% CI: 0.48–0.60; p<0.01) and 6-month (C = 0.79, 95% CI: 0.76–0.83, versus 0.56, 95% CI: 0.52–0.60; p<0.01) mortality. Among STEMI patients, the GRACE and TIMI STEMI scores demonstrated comparably excellent discrimination for in-hospital (C = 0.84, 95% CI: 0.78–0.90 versus 0.83, 95% CI: 0.78–0.89; p = 0.83) and 6-month (C = 0.72, 95% CI: 0.63–0.81, versus 0.71, 95% CI: 0.64–0.79; p = 0.79) mortality. An analysis of refitted multivariate models demonstrated a marked improvement in the discriminative power of the TIMI UA/NSTEMI model with the incorporation of heart failure and hemodynamic variables. Study limitations included unaccounted for confounders inherent to observational, single institution studies with moderate sample sizes.
The GRACE scores provided superior discrimination as compared with the TIMI UA/NSTEMI score in predicting in-hospital and 6-month mortality in UA/NSTEMI patients, although the GRACE and TIMI STEMI scores performed equally well in STEMI patients. The observed discriminative deficit of the TIMI UA/NSTEMI score likely results from the omission of key risk factors rather than from the relative simplicity of the scoring system.
The location of acute myocardial infarction (MI) is an important prognostic factor for risk stratification of patients with first ST-segment elevation MI (STEMI). The main goal of this study was to compare the severity and extension of coronary involvement in inferior and anterior MI.
This study reviewed angiographic reports of 579 patients with a first anterior wall STEMI and 690 with a first inferior STEMI that were referred to Tehran Heart Center between March 2004 and September 2007. The number of coronary vessels involvement and the presence of left main lesion were determined based on angiography reports. The Gensini score was also calculated for each patient from the coronary arteriogram.
Incidence of left main lesion was similar between the two groups. Although coronary arteries involvement according to Gensini score was more severe in anterior wall MI group compared with inferior wall MI group, the number of involved coronary arteries was significantly higher in the inferior MI patients. Recommendation of coronary artery bypass grafting, percutaneous coronary intervention (PCI) or medical treatment were the same for both groups; however, patients with anterior MI were treated more with primary PCI.
According to our angiography database, despite anterior wall MI is associated with more severity of coronary artery disease; inferior wall MI is more extent with regard to the number of involved coronary vessels. Location of MI can predict the severity and extension of infarction.
Myocardial Infarction; Coronary Vessels; Angiography
The Thrombolysis In Myocardial Infarction (TIMI) risk index for the prediction of 30-day mortality was developed and validated in patients with ST-segment elevation myocardial infarction (STEMI) who were being treated with thrombolytics in randomized clinical trials. When tested in clinical registries of patients with STEMI, the index performed poorly in an older (65 years and older) Medicare population, but it was a good predictor of early death among the more representative population on the National Registry of Myocardial Infarction-3 and -4 databases. It has not been tested in a population outside the United States or among non-STEMI patients.
The TIMI risk index was applied to the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study cohort of 11,510 acute MI patients from Ontario. The model’s discriminatory capacity and calibration were tested in all patients and in subgroups determined by age, sex, diagnosis and reperfusion status.
The TIMI risk index was strongly associated with 30-day mortality for both STEMI and non-STEMI patients. The C statistic was 0.82 for STEMI and 0.80 for non-STEMI patients, with overlapping 95% CI. The discriminatory capacity was somewhat lower for patients older than 65 years of age (0.74). The model was well calibrated.
The TIMI risk index is a simple, valid and moderately accurate tool for the stratification of risk for early death in STEMI and non-STEMI patients in the community setting. Its routine clinical use is warranted.
Coronary disease; Myocardial infarction; Risk factors
Risk stratification in ST-elevation myocardial infarction (STEMI) is important, such that the most resource intensive strategy is used to achieve the greatest clinical benefit. This is essential in developing countries with wide variation in health care facilities, scarce resources and increasing burden of cardiovascular diseases. This study sought to validate the Thrombolysis In Myocardial Infarction (TIMI) risk score for STEMI in a multi-ethnic developing country.
Data from a national, prospective, observational registry of acute coronary syndromes was used. The TIMI risk score was evaluated in 4701 patients who presented with STEMI. Model discrimination and calibration was tested in the overall population and in subgroups of patients that were at higher risk of mortality; i.e., diabetics and those with renal impairment.
Compared to the TIMI population, this study population was younger, had more chronic conditions, more severe index events and received treatment later. The TIMI risk score was strongly associated with 30-day mortality. Discrimination was good for the overall study population (c statistic 0.785) and in the high risk subgroups; diabetics (c statistic 0.764) and renal impairment (c statistic 0.761). Calibration was good for the overall study population and diabetics, with χ2 goodness of fit test p value of 0.936 and 0.983 respectively, but poor for those with renal impairment, χ2 goodness of fit test p value of 0.006.
The TIMI risk score is valid and can be used for risk stratification of STEMI patients for better targeted treatment.
Ischemic time is a major determinant of infarct size in ST segment elevation myocardial infarction (STEMI). Emphasis is placed on reducing the door-to-reperfusion therapy time component, whereas the symptom-to-door time is often overlooked.
To correlate the symptom-to-door time with left ventricular ejection fraction (LVEF) in patients with STEMI.
Acute Myocardial Infarction (AMI)-McGill was a cohort study of consecutive patients with STEMI who presented to three adult university hospitals. Multivariate linear regression was performed to correlate the symptom-to-door time with postinfarction LVEF adjusted for reperfusion method, prior myocardial infarction and components of the Thrombolysis In Myocardial Infarction (TIMI) risk score.
There were 188 patients, with a mean age of 66 years. On arrival to hospital, 23% of patients were in Killip class II to IV and 87% received reperfusion therapy (20% fibrinolytic therapy and 67% primary percutaneous coronary intervention). The median symptom-to-door time was 120 min (first quartile: 60 min, third quartile: 290 min) and the median door-to-reperfusion therapy time was 93 min (first quartile: 54 min, third quartile: 155 min). Three variables were independently correlated with LVEF in the study’s regression model: symptom-to-door time (beta: –0.66, 95% CI –1.18 to –0.14; P=0.01), Killip class II to IV on arrival (beta: –6.43, 95% CI –11.87 to –0.99; P=0.02) and anterior territory of the infarction (beta: –5.86, 95% CI –10.55 to –1.18; P=0.02).
Symptom-to-door time was negatively correlated with postinfarction LVEF in patients with STEMI. Strategies to shorten this delay, such as educating high-risk patients about the symptoms of AMI, should be considered.
Angioplasty; Echocardiography; Fibrinolysis; Myocardial infarction; Thrombolysis
The worse prognosis in patients without ST-elevation (non-STEMI) as compared to ST-elevation myocardial infarction (STEMI), may be due to treatment differences. We aimed to evaluate the differences in characteristics, treatment and outcome in patients with non-STEMI versus STEMI in an unselected patient population.
Individual patient data from all patients in our hospital with a discharge diagnosis of MI between Jan 2001 and Jan 2002 were evaluated. Follow-up data were obtained until December 2004. Patients were categorized according to the presenting electrocardiogram into non-STEMI or STEMI.
A total of 824 patients were discharged with a diagnosis of MI, 29% with non-STEMI and 71% with STEMI. Patients with non-STEMI were significantly older and had a higher cardiovascular risk profile. They underwent less frequently coronary angiography and revascularization and received less often clopidogrel and ACE-inhibitor on discharge. Long-term mortality was significantly higher in the non-STEMI patients as compared to STEMI patients, 20% vs. 12%, p = 0.006, respectively. However, multivariate analysis showed that age, diabetes, hypertension and no reperfusion therapy (but not non-STEMI presentation) were independent and significant predictors of long-term mortality.
In an unselected cohort of patients discharged with MI, there were significant differences in baseline characteristics, and (invasive) treatment between STEMI and non-STEMI. Long-term mortality was also different, but this was due to differences in baseline characteristics and treatment. More aggressive treatment may improve outcome in non-STEMI patients.
Although the Thrombolysis In Myocardial Infarction (TIMI) score incorporates ST deviation, it does not account for characteristics of the ST deviations. In the present study, it was hypothesized that the magnitude and characteristics of ST deviation may add to the prognostic values of the TIMI risk score in acute coronary syndrome (ACS) patients, particularly in lower-risk patients with a TIMI risk score of less than 5.
To evaluate the prognostic value of combining the TIMI risk score and characteristics of ST deviation in patients with non-ST elevation ACS and a TIMI risk score of less than 5.
The death/myocardial infarction (MI) rates of 1296 patients enrolled in the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) angiographic substudy were examined.
Patients without a TIMI risk score of 5 or greater, and without an ST deviation of 1 mm or greater had the lowest six-month rate of death/MI (5%). In patients with a TIMI risk score of less than 5, the six-month death/MI rate was increased in those with ST depression of 2 mm or greater compared with patients with a similar TIMI risk score and without ST deviation of 1 mm or greater (24% versus 5%, P<0.001). The presence of ST deviation of 2 mm or greater identified an additional 15% of patients with an increased six-month death/MI rate in patients with a TIMI risk score of less than 5.
ST segment deviation of 2 mm or greater confers additional prognostic information in non-ST elevation ACS patients with a TIMI risk score of less than 5. Patients with a TIMI risk score of less than 5 and ST deviation of 2 mm or less had the lowest risk of six-month death/MI.
Acute coronary syndromes; Electrocardiogram; Non-ST elevation myocardial infarction; Unstable angina
Pre-hospital electrocardiogram (ECG) transmission to an expert for interpretation and triage reduces time to acute percutaneous coronary intervention (PCI) in patients with ST elevation Myocardial Infarction (STEMI). In order to detect all STEMI patients, the ECG should be transmitted in all cases of suspected acute cardiac ischemia. The aim of this study was to examine the ability of an artificial neural network (ANN) to safely reduce the number of ECGs transmitted by identifying patients without STEMI and patients not needing acute PCI.
Five hundred and sixty ambulance ECGs transmitted to the coronary care unit (CCU) in routine care were prospectively collected. The ECG interpretation by the ANN was compared with the diagnosis (STEMI or not) and the need for an acute PCI (or not) as determined from the Swedish coronary angiography and angioplasty register. The CCU physician's real time ECG interpretation (STEMI or not) and triage decision (acute PCI or not) were registered for comparison.
The ANN sensitivity, specificity, positive and negative predictive values for STEMI was 95%, 68%, 18% and 99%, respectively, and for a need of acute PCI it was 97%, 68%, 17% and 100%. The area under the ANN's receiver operating characteristics curve for STEMI detection was 0.93 (95% CI 0.89-0.96) and for predicting the need of acute PCI 0.94 (95% CI 0.90-0.97). If ECGs where the ANN did not identify a STEMI or a need of acute PCI were theoretically to be withheld from transmission, the number of ECGs sent to the CCU could have been reduced by 64% without missing any case with STEMI or a need of immediate PCI.
Our ANN had an excellent ability to predict STEMI and the need of acute PCI in ambulance ECGs, and has a potential to safely reduce the number of ECG transmitted to the CCU by almost two thirds.
Objective: To evaluate the impact of routine stenting, compared with balloon angioplasty, in unselected patients presenting with ST segment elevation myocardial infarction (STEMI).
Design: Randomised trial.
Setting: Tertiary referral centre.
Participants: All patients presenting with STEMI randomly assigned to stenting or balloon angioplasty. No exclusion criteria were applied.
Main outcome measure: The primary end point was combined death or reinfarction at one year’s follow up.
Results: 1683 consecutive patients with STEMI were randomly assigned before angiography to stenting (n = 849) or balloon angioplasty (n = 834). A total of 785 patients (92.5%) in the stent group and 763 patients (91.5%) in the balloon group actually underwent primary angioplasty. The groups were comparable in terms of postprocedural TIMI (thrombolysis in myocardial infarction) flow, myocardial blush grade, and distal embolisation. No difference was observed in clinical outcome at both intention to treat (14% v 12.5%, not significant) and actual treatment analyses (12.4% v 11.3%, not significant).
Conclusions: Compared with balloon angioplasty, routine stenting does not seem to reduce death and reinfarction in a large cohort of unselected patients with STEMI.
primary stenting; myocardial infarction; real world angioplasty
Background and Objectives
Aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI) is an effective adjunctive therapy for ST-segment elevation myocardial infarction (STEMI). An elevated neutrophil count in STEMI is associated with microvascular dysfunction and adverse outcomes. We evaluated whether AT can improve microvascular dysfunction in patients with STEMI and an elevated neutrophil count.
Subjects and Methods
Seventy patients with STEMI undergoing primary PCI from August 2007 to February 2009 in our institution were classified by tertiles of neutrophil count on admission (<5,300/mm3, 5,300-7,600/mm3, and >7,600/mm3). The angiographic outcome was post-procedural thrombolysis in myocardial infarction (TIMI) flow grade. Microvascular dysfunction was assessed by TIMI myocardial perfusion (TMP) grade and ST-segment resolution on electrocardiography 90 minutes after PCI. The clinical outcome was major adverse cardiac event (MACE), defined as cardiac death, re-infarction, and target lesion revascularization at 9 months.
There were no significant differences in the clinical characteristics and pre- and post-procedural TIMI flow grades between the neutrophil tertiles. As the neutrophil count increased, a lower tendency toward TMP grade 3 (83% vs. 52% vs. 54%, p=0.06) and more persistent residual ST-segment elevation (>4 mm: 13% vs. 26% vs. 58%, p=0.005) was observed. The 9-month MACE rate was similar between the groups. On subgroup analysis of AT patients (n=52) classified by neutrophil tertiles, the same tendency toward less frequent TMP grade 3 (77% vs. 56% vs. 47%, p=0.06) and persistent residual ST-segment elevation (>4 mm: 12% vs. 28% vs. 53%, p=0.05) was observed as neutrophil count increased.
A higher neutrophil count at presentation in STEMI is associated with more severe microvascular dysfunction after primary PCI, which is not improved with AT.
Myocardial infarction; Neutrophils
Younger, but not older, women have a higher mortality than men of similar age after a myocardial infarction (MI). We sought to determine whether this relationship is true for both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI).
Retrospective cohort study.
1057 USA hospitals participant in the National Registry of Myocardial Infarction between 2000 and 2006.
126 172 STEMI and 235 257 NSTEMI patients.
Main outcome measure
For both STEMI and NSTEMI, the younger the patient's age, the greater the excess mortality risk for women compared with men, while older women fared similarly (STEMI) or better (NSTEMI) than men (p<0.0001 for the age–sex interaction). In STEMI, the unadjusted women-to-men RR was 1.68 (95% CI 1.41 to 2.01), 1.78 (1.59 to 1.99), 1.45 (1.34 to 1.57), 1.08 (1.02 to 1.14) and 1.03 (0.98 to 1.07) for age <50 years, age 50–59, age 60–69, age 70–79 and age 80–89, respectively. For NSTEMI, corresponding unadjusted RRs were 1.56 (1.31 to 1.85), 1.42 (1.27 to 1.58), 1.17 (1.09 to 1.25), 0.92 (0.88 to 0.96) and 0.86 (0.83 to 0.89). After adjusting for risk status, the excess risk for younger women compared with men decreased to approximately 15–20%, while a better survival of older NSTEMI women compared with men persisted.
Sex-related differences in short-term mortality are age-dependent in both STEMI and NSTEMI patients.
The TIMI (Thrombolysis In Myocardial Infarction) risk score is a seven item risk stratification tool derived from trials of patients with non‐ST segment elevation acute coronary syndromes (ACS) that has been validated in emergency department (ED) patients with potential ACS. We hypothesised that it might have different prognostic abilities in male and female patients.
This was a prospective cohort study of ED patients with potential ACS. Data included demographics, medical and cardiac history, and components of the TIMI risk score. Investigators followed the hospital course daily. The main outcome was death, acute myocardial infarction (AMI), or revascularisation within 30 days as stratified by TIMI risk score and compared between genders using χ2 tests.
There were 2022 patients enrolled: 1204 (60%) females and 818 (40%) males. The incidence of 30 day death, AMI, revascularisation (n = 168) according to TIMI score is as follows (female vs male): TIMI 0 (n = 670), 1.6% vs 2.0%, p = 0.2; TIMI 1 (n = 525), 4.6% vs 8.5%, p = 0.02; TIMI 2 (n = 378), 6.3% vs 10.4%, p = 0.05; TIMI 3 (n = 234), 6.5% vs 24.6%, p<0.001; TIMI 4 (n = 157), 22.7% vs 24.4%, p = 0.15; TIMI 5 (n = 52), 35.5% vs 39.1%, p = 0. 2; TIMI 6 or 7 (n = 6), 33.3% vs 66.7%, p = 1.0. The relationship between TIMI score and outcome was highly significant (p<0.001) for each gender; however, males tended to have worse outcomes at lower TIMI risk scores.
The TIMI risk score successfully risk stratifies both males and females with potential ACS at the time of ED presentation; however, males have worse outcomes at lower TIMI scores than females.
Background. Myocardial blush grade (MBG) and myocardial contrast echocardiography (MCE) are both indices for myocardial perfusion in patients with ST-elevation acute myocardial infarction (STEMI). We aimed to compare MBG with MCE in the infarct-related artery segment for assessing infarct size in patients with STEMI treated with primary percutaneous coronary intervention (PCI).
Methods. 43 patients underwent successful (postprocedural TIMI flow 3) primary PCI for STEMI. MBG was assessed at the end of the PCI procedure and MCE was assessed 1.7±1.8 days after PCI. Enzymatic infarct size was estimated by measurementof enzyme activities by using lactate dehydrogenase (LDH) as the referenceenzyme. Cumulative enzyme release (LDHQ48) from at least five serial measurements up to 48 hours after symptom onset was calculated. Also peak creatine kinase, CK-MB and peak LDH were measured.
Results. MBG 0/1, 2 and 3 were observed in 14, 12 and 17 patients, respectively, and was compared with tertiles of MCE. We found a parallel correlation between both MBG and MCE and LDHQ48. However, there was no correlation between MCE and MBG. Patients with both normal MCE and a normal MBG had least myocardial damage and those with both impaired MCE and an impaired MBG had most myocardial damage.
Conclusion. Both MBG and MCE are good predictors of infarct size in STEMI patients treated with PCI. However, these markers are not mutually related, possibly due to time-related changes in myocardial perfusion. Combining these two markers may yield a more accurate prediction of final myocardial damage. (Neth Heart J 2010;18:25-30.)
ST-segment elevation myocardial infarction; myocardial blush grade; myocardial contrast echocardiography; infarct size
The Thrombolysis in Myocardial Infarction (TIMI) risk score uses clinical data to predict the short-term risk of acute myocardial infarction, coronary revascularization or death from any cause. It was originally developed for use in patients with unstable angina or non–ST-elevation myocardial infarction. We sought to expand the clinical application of the TIMI risk score by assessing its prognostic accuracy in patients in the emergency department with potential acute coronary syndromes.
We searched five electronic databases, hand-searched reference lists of included studies and contacted content experts to identify articles for review. We included prospective cohort studies that validated the TIMI risk score in emergency department patients. We performed a meta-regression to determine whether a linear relation exists between TIMI risk score and the cumulative incidence of cardiac events.
We included 10 prospective cohort studies (with a total of 17 265 patients) in our systematic review. Data were available for meta-analysis in 8 of the 10 studies. Of patients with a score of zero, 1.8% had a cardiac event within 30 days (sensitivity 97.2%, 95% CI 96.4–97.8; specificity 25.0%, 95% CI 24.3–25.7; positive likelihood ratio 1.30, 95% CI 1.28–1.31; negative likelihood ratio 0.11, 95% CI 0.09–0.15). Meta-regression analysis revealed a strong linear relation between TIMI risk score (p < 0.001) and the cumulative incidence of cardiac events.
Although the TIMI risk score is an effective risk stratification tool for patients in the emergency department with potential acute coronary syndromes, it should not be used as the sole means of determining patient disposition.
The expression of pregnancy-associated plasma protein A (PAPP-A) was identified by immunohistochemistry (IHC) in culprit atherothrombotic plaque specimens harvested from patients admitted with ST-segment elevation myocardial infarction (STEMI).
The atherothrombotic samples were collected from a consecutive cohort consisting of 20 individuals admitted with STEMI to Stavanger University Hospital, Norway, from 2005-2006, presenting angiographically with an acute thrombotic occlusion of a coronary artery characterized by TIMI flow 0. The atherothrombotic plaques were obtained by aspiration thrombectomy during percutaneous coronary intervention within 12 hours from the onset of symptoms and prepared for IHC analysis.
In the IHC analysis staining for PAPP-A occurred in the extracellular matrix of the plaques and no evidence of staining for PAPP-A was found in the thrombi.
Our results indicate that in vivo PAPP-A is strongly expressed in atherothrombotic plaques harvested from patients admitted with STEMI, as documented by IHC.
OBJECTIVE—To investigate the value of non-invasive reperfusion indices in acute myocardial infarction, avoiding the possible need for acute coronary angiography and subsequent angioplasty.
DESIGN—In a prospective angiographic study, seven potential ECG or clinical markers of reperfusion were analysed in 230 patients with acute myocardial infarction. In all patients two 12 lead ECGs were used: the ECG on admission and the ECG immediately before coronary angiography. Non-invasive markers of reperfusion determined just before coronary angiography were prospectively correlated to thrombolysis in myocardial infarction (TIMI) flow. Data analysis correlated these non-invasive indices with coronary flow (analysis A: TIMI 2-3 v TIMI 0-1 flow; analysis B: TIMI 3 v TIMI 0-2 flow).
RESULTS—A sudden decrease in chest pain was the most common sign of reperfusion (36%), followed by reduction in ST segment elevation by ⩾ 50% (30%), and the development of a terminal negative T wave (20%) in the lead with the highest ST segment elevation. Reduction in ST segment elevation by ⩾ 50% and the appearance of an accelerated idioventricular rhythm (AIVR) had the highest positive predictive value for reperfusion. For analyses A and B, the positive predictive values were 85% and 66% for resolution of ST segment elevation, and 94% and 59% for AIVR, respectively. The presence of three or more non-invasive markers of reperfusion predicted TIMI 3 flow accurately in 80% of cases.
CONCLUSIONS—The prospective use of non-invasive indices of reperfusion is simple, practical, and can be of value in assessing coronary patency in patients admitted with acute myocardial infarction. Using these indices, discrimination between TIMI 0-1 and TIMI 2-3 flow can be made with good accuracy. However, TIMI 3 flow cannot be determined reliably. The use of such non-invasive indices depends on the goal of reperfusion.
Keywords: reperfusion indices; acute myocardial infarction
Admission white blood cell (WBC) count and thrombosis in myocardial infarction (TIMI) risk score have been associated with adverse outcomes after acute myocardial infarction (AMI). This study investigated the joint effect of WBC count and TIMI risk score on predicting in-hospital outcomes in patients with AMI.
Materials and Methods:
WBC count and TIMI risk score were measured at the time of hospital admission in 70 patients with AMI. Echocardiogram was done on prior to discharge by a cardiologist and ejection fraction (EF) was determined according to the Simpson formula. Patients were stratified into tertiles (low and high) based on WBC count and TIMI risk score.
Patients with a high WBC count had a 5.0-fold increase in-hospital congestive heart failure and 2.2 increases in mortality compared with those with a low WBC count. Patients with a high TIMI risk score had a 10-fold increase in congestive heart failure presentation and mortality compared with those with a low TIMI risk score. When a combination of different strata for each variable was analyzed, a stepwise increase in mortality was seen. There were a few number of patients with a high WBC count and low TIMI risk score or with a low WBC count and high TIMI risk score. These patients had an intermediate risk, whereas those with a high WBC count and TIMI risk score had the highest risk.
These findings suggested that a simple combination of WBC count and TIMI risk score might provide further information for predicting outcomes in patients with AMI.
Heart failure; infarction; ST elevation myocardial; white blood cell
Left ventricular (LV) dysfunction heart failure is one of the causes of morbidity and mortality following ST elevation myocardial infarction (STEMI). This study was done to determine the clopidogrel effect in preventing reduced LV function in patients with STEMI.
In this study, 144 patients with STEMI admitted to the Isfahan University of Medical Sciences hospitals were followed in two groups for one month. The case group received Clopidogrel, 300 mg, on admission and then, 75 mg daily, while the control group received routine therapy for STEMI without Clopidogrel. Left ventricular ejection fraction (LVEF) on the 4th day and one month after STEMI was measured by echocardiography. The results of LVEF were compared within and between groups.
The mean LVEF in the case group on the 4th day and one month after STEMI were 45.92 and 52.15%, respectively (P<0.001). The mean LVEF in the control group on 4th day and one month after STEMI were 44.72 and 42.71%, respectively.
We suggest that Clopidogrel is effective in prevention of LVEF reduction in patients with STEMI.
Heart failure; Myocardial infarction; Prevention
Angiographic flow in an epicardial artery does not define perfusion at the microvascular level.
To compare myocardial contrast echocardiography (MCE) with angiographic methods of assessing microvascular reperfusion in patients with acute myocardial infarction (AMI).
One hundred consecutive patients with a first ST segment elevation myocardial infarction and single-vessel disease were successfully treated with primary percutaneous coronary intervention. Regional contrast score index (RCSI), corrected Thrombolysis In Myocardial Infarction (TIMI) frame count (cTFC), TIMI myocardial perfusion grade (TMPG) and myocardial blush grade were evaluated.
Among 717 asynergic segments on MCE, 168 revealed a lack of perfusion. TMPG and cTFC correlated significantly with RCSI (P=0.031 and P=0.027, respectively). Myocardial blush grade did not correlate with RCSI (P=0.067). Patients with anterior AMI had significantly more segments with a perfusion defect on MCE than patients with inferior AMI (P=0.0001).
MCE results correlate with angiographic methods of perfusion assessment such as TMPG and cTFC. Anterior AMI is associated with a greater extent of perfusion defect. MCE results correlate also with recovery of systolic left ventricular function and clinical outcome at six month follow-up.
Contrast echocardiography; Coronary angiography; Myocardial infarction; Myocardial perfusion
The Thrombolysis in Myocardial Infarction (TIMI) risk score (TRS) has proven value in predicting prognosis in unstable angina/non ST-elevation myocardial infarction (NSTEMI) as well as in ST-elevation myocardial infarction. The TRS system has little implication, however, in the extent of myocardial damage in high-risk patients with NSTEMI. A total of 1621 patients (63.6±12.2 years; 1043 males) with NSTEMI were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR). We analyzed the risk for major adverse cardiac events (MACE) during a 6-month follow-up period. The TRS system showed good correlation with MACE for patients in the low and intermediate groups but had poor correlation when the high-risk group was included (p=0.128). The MACE rate was 3.8% for TRS 1, 9.4% for TRS 2, 10.7% for TRS 3, and 12.3% for TRS 4 (HR=1.29, p=0.026). Among the biomarkers and clinical risk factors, elevated N-terminal pro-brain natriuretic peptide (NT-proBNP) (HR=2.61, p=0.001) and Killip class above III showed good correlation with MACE (HR=0.302, p<0.001). Therefore, we revised an alternative clinical scoring system by including these two variables that reflect left ventricular dysfunction: age > 65 years, history of ischemic heart disease, Killip class above III, and elevated pro-BNP levels above the 75th percentile. This modified scoring system, when tested for validity, showed good predictive value for MACE (HR=1.64, p<0.001). Compared with the traditional TRS, the novel alternative scoring system based on age, history of ischemic heart disease, Killip class, and NT-proBNP showed a better predictive value for 6-month MACE in high-risk patients with NSTEMI.
Angina, unstable; Mortality; Myocardial Infarction
Clinical trials comparing thrombectomy devices with conventional percutaneous coronary interventions (PCI) in patients with acute ST elevation myocardial infarction (STEMI) have produced conflicting results. The objective of our study was to systematically evaluate currently available data comparing thrombectomy followed by PCI with conventional PCI alone in patients with acute STEMI.
Seventeen randomized trials (n = 3,909 patients) of thrombectomy versus PCI were included in this meta-analysis. We calculated the summary odds ratios for mortality, stroke, post procedural myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) grade flow, and post procedural ST segment resolution (STR) using random-effects and fixed-effects models.
There was no difference in risk of 30-day mortality (44/1914 vs. 50/1907, OR 0.84, 95% CI 0.54-1.29, P = 0.42) among patients randomized to thrombectomy, compared with conventional PCI. Thrombectomy was associated with a significantly greater likelihood of TIMI 3 flow (1616/1826 vs. 1533/1806, OR 1.41, P = 0.007), MBG 3 (730/1526 vs. 486/1513, OR 2.42, P < 0.001), STR (923/1500 vs. 715/1494, OR 2.30, P < 0.001), and with a higher risk of stroke (14/1403 vs. 3/1413, OR 2.88, 95% CI 1.06-7.85, P = 0.04). Outcomes differed significantly between different device classes with a trend towards lower mortality with manual aspiration thrombectomy (MAT) (21/949 vs.36/953, OR 0.59, 95% CI 0.35-1.01, P = 0.05), whereas mechanical devices showed a trend towards higher mortality (20/416 vs.10/418, OR 2.07, 95% CI 0.95-4.48, P = 0.07).
Thrombectomy devices appear to improve markers of myocardial perfusion in patients undergoing primary PCI, with no difference in overall 30-day mortality but an increased likelihood of stroke. The clinical benefits of thrombectomy appear to be influenced by the device type with a trend towards survival benefit with MAT and worsening outcome with mechanical devices.
Growing evidence suggests that poor coronary blood flow after primary percutaneous coronary intervention (PCI) is associated with unfavorable clinical out-come. We retrospectively evaluated data from our single center “real world patients” database of patients undergoing primary PCI to determine differences in clinical and angiographic patterns in patients with or without restoring thrombolysis in myocardial infarction (TIMI) flow 3.
Methods and results
Between 2001 and 2006, 500 patients underwent primary PCI for STEMI. In 430 patients, post-interventional TIMI flow 3 could be established. In this group, in-hospital mortality was significant lower (6.4% Vs. 32.9%; P < 0.0001), left ventricular ejection fraction was better (51.3 Vs. 44.2%; P < 0.0001), and prehospital fibrinolytic therapy (6.3% Vs. 14.3%; P = 0.015), cardiogenic shock (10.9% Vs. 24.3%; P = 0.002) and use of intra-aortic balloon pump were all more unlikely (5.8% Vs. 11.4%; P = 0.045) compared to patients with TIMI flow ≤ 2. In patients with post-interventional TIMI flow ≤ 2 the left anterior descending coronary artery (LAD) was significantly more often seen as the target vessel (54.3% Vs. 44.6%; P = 0.039). A regressions analysis showed that predictors leading to such flow patterns are diabetes (P = 0.013), pre-hospital fibrinolytic therapy (P = 0.017), cardiogenic shock (P = 0.002) and a 3-vessel disease (P = 0.003). After 6 months, patients without restored normal TIMI flow had worse New York Heart Association functional class (NYHA), and had to undergo repeat coronary angiography more often.
Post-interventional TIMI flow ≤ 2 is strongly associated with adverse out-come during hospitalization and after 6 months following hospitalization.
TIMI flow; primary percutaneous coronary intervention; acute myocardial infarction; follow up; no reflow phenomenon
The study aim was to compare two different stress echocardiography interpretation techniques based on the correlation with thrombosis in myocardial infarction (TIMI ) flow grading from acute coronary syndrome (ACS) patients. Forty-one patients with suspected ACS were studied before diagnostic coronary angiography with myocardial contrast echocardiography (MCE) at rest and at stress. The correlation of visual interpretation of MCE and TIMI flow grade was significant. The quantitative analysis (myocardial perfusion parameters: A, β, and A × β) and TIMI flow grade were significant. MCE visual interpretation and TIMI flow grade had a high degree of agreement, on diagnosing myocardial perfusion abnormality. If one considers TIMI flow grade <3 as abnormal, MCE visual interpretation at rest had 73.1% accuracy with 58.2% sensitivity and 84.2% specificity and at stress had 80.4% accuracy with 76.6% sensitivity and 83.3% specificity. The MCE quantitative analysis has better accuracy with 100% of agreement with different level of TIMI flow grading. MCE quantitative analysis at stress has showed a direct correlation with TIMI flow grade, more significant than the visual interpretation technique. Further studies could measure the clinical relevance of this more objective approach to managing acute coronary syndrome patient before percutaneous coronary intervention (PCI).
Background. We investigated the association between clinical characteristics, angiographic data and ventricular arrhythmia in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI)
Methods. In patients with STEMI (n=225), a Holter analysis was performed the first 12 hours after primary PCI.
Results. A total of 151 (66%) patients had ≥1 episode of ventricular tachycardia (VT). Age <70 years (RR 4.9, 95% CI 1.8 to 12.7), TIMI 0-1 pre-PCI (RR 2.6, 95% CI 1.1 to 6.1) and peak CK (RR 3.5, 95% CI 1.9 to 5.8) were independent predictors of VT. One-year mortality was 7%, no association between mortality and presence of early VT was found.
Conclusion. Ventricular tachycardia is common in the first 12 hours after primary PCI for STEMI. Independent predictors of VT are younger age, TIMI 0-1 flow prior to PCI and larger infarct size. The presence of early VT was not significantly associated with one-year mortality. (Neth Heart J 2010;18:122–8.20390062)
Arrhythmias, Cardiac; Percutaneous Coronary; Myocardial Infarction; Prognosis; Tachycardia, Ventricular; Ventricular Fibrillation