Percutaneous coronary intervention increases microvascular resistance in patients with non-ST-elevation acute coronary syndrome
Cansu AkdenizSabahattin UmmanYílmaz NişancíBerrin UmmanZehra BuğraEmre AslangerAbdullah KaplanAkar YılmazErhan TekerGöksel GüzNihat PolatMurat Sezer
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In the acute coronary syndrome setting, the interaction between epicardial coronary artery stenosis and microcirculation subtended by the culprit vessel is poorly understood. The purpose of the present study was to assess the immediate impact of percutaneous coronary intervention (PCI) on microvascular resistance (MR) in patients with non-ST-elevation myocardial infarction (NSTEMI).Thirty-eight patients undergoing PCI for NSTEMI were recruited consecutively. Culprit lesions were stented over a Doppler and pressure-sensor-equipped guidewire. In the presence of epicardial stenosis, MR was calculated by taking collateral flow, as measured by the coronary wedge pressure, into consideration. After removal of epicardial stenosis, MR was calculated simply as distal coronary pressure divided by average peak velocity. When collateral flow was incorporated into the calculation, MR increased significantly from 1.70 ± 0.76 to 2.05 ± 0.72 (p=0.001) after PCI in the whole population. Periprocedural changes (Δ) in absolute values of MR and troponin T correlated significantly (r=0.629, p=0.0001). In patients who developed periprocedural myocardial infarction, MR increased significantly after PCI (1.48 ± 0.73 versus 2.28 ± 0.71, p<0.001). Nevertheless, removal of the epicardial lesion did not change MR in patients without periprocedural MI (1.91±0.73 versus 1.81±0.67, p=0.1).When collateral flow is accounted for, removal of epicardial stenosis increases MR in patients with NSTEMI undergoing PCI.Keywords:
Culprit
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Fractional Flow Reserve
【Objective】To evaluate the efficacy and safety between immediate and selective percutaneous coronary intervention(PCI) in patients with ST-segment elevation myocardial infarction(STEMI) with TIMI grade 3.【Methods】86 cases of patients with acute STEMI,which coronary angiography showed TIMI flow grade 3,were divided randomly into immediate PCI group(44 cases,PCI was implemented immediately when hospitalized) and selective PCI group(42 cases,PCI was implemented at 7～10 days after STEMI).The success rate of procedural implantation of stent,the incidence of intraoperative slow flow or no-reflow and adverse cardiovascular events during hospitalization,the hospitalized stay and left ventricular ejection fraction(LVEF) at 4 weeks after PCI were observed.【Results】The success rate of stent implantation in the selective PCI group was 100%,significantly higher than 88.64% in the immediate PCI group(P 0.05).The incidence of intra-operative slow flow or no-reflow in immediate PCI group was 11.36%,while no case was found in selective PCI group(P 0.05).The rate of the adverse cardiovascular events during hospitalization was 4.54% in immediate PCI group,while no event was found in the selective PCI group(P 0.05),but LVEF at 4 weeks after PCI and the hospitalized time were not significant different between the both groups(P 0.05).【Conclusions】The findings suggested that selective PCI was better than immediate PCI in the clinical efficacy and security for STEMI patients with TIMI 3 blood flow.
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To investigate the safety and efficacy of early percutaneous coronary intervention (early PCI) in patients with non-ST Segment elevation infarction (NSTEMI) undergoing elective PCI.Methods
Ninety-one patients (79 males) who suffered from first NSTEMI within 24 h from symptom onset during October 2009 and July 2010 were enrolled in this study. All the cases were randomly divided into early PCI group (n=44) and elective PCI group (n=47). PCI was performed immediately after admission in early PCI group. Patients in elective PCI group received the same medical therapies with those in early PCI group, and PCI was performed 7–10 days after admission. TIMI flow of IRA before and after PCI, as well as TIMI Myocardial perfusion grading (TMP) after PCI were compared between the two groups. The differences of left ventricular function and MACE during hospitalisation and 6-month follow-up were analysed.Results
Baseline characteristics were similar between the two groups. There were no differences in the rates of IRA total occlusion, TIMI flow grade 1, and TIMI flow grade 2 before PCI between the two groups (all p>0.05), while the rate of TIMI flow grade 3 in early PCI group was lower than that in elective group (22.73% vs 42.55%, p<0.05). After PCI treatment, no significant differences in TIMI flow were found between the two groups, and the rate of TMP grade 2 or greater in early PCI group was higher (79.55% vs 59.57%, p<0.05). There were no significant differences in LVEDV, LVESV, and LVEF between the two groups in hospital (all p>0.05). After 6-month follow-up, both LVEDV and LVESV decreased significantly, and LVEF increased. The incidence of cardiac rehospitalisation was lower in early PCI group, while the cardiac death, severe heart failure, reinfarction, malignant arrhythmias, revasculisation of IRA, and bleeding complications were similar.Conclusions
Both early and elective PCI can improve the heart function in NSTEMI patients at 6 months, and the effects of early PCI on improving heart function is better without increase of bleeding complications.TIMI
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To assess Thrombolysis In Myocardial Infarction (TIMI) flow of the nation-produced tirofiban in patients with ST-segment elevation myocardial infarction (STEMI) during primary Percutaneous Coronary Intervention (PCI).Methods
120 patients with STEMI during primary PCI from Nov 2006 to June 2009 were divided into two groups, tirofiban+PCI group of 60 cases (51 males and 9 females) with mean age (60.11±10.96) years old, and the other primary PCI group of 60 cases (42 males and 18 females) with mean age (64.33±11.91) years. The TIMI flow before and after operation were observed in all cases angiographically.Results
By using tirofiban before operation improved TIMI flow, a greater percentage of TIMI 1 grade flow was achieved in the tirofiban+PCI group compared with the primary PCI group before operation (13.3.8% vs 3.3%, p>0.05). There was no difference of TIMI 3 grade flow between the two groups after operation, TIMI 2 grade flow was lesser in tirofiban+PCI group (6.7% vs 3.4%, p>0.05).Reperfusion arrhythmia was lesser in tirofiban+PCI group (3.4% vs 6.7%).Conclusion
Tirofiban may improve TIMI flow of the IRA in patients with STEMI during emergency PCI.TIMI
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Objective To eveluate the effect of tirofiban on TIMI flow in patients with STEMI during primary PCI. Methods Forty-eight patients with STEMI who underwent primary PCI were randomly divided into two groups which were: the tirofiban+PCI group (n=27) and the primary PCI group (n=21). The TIMI flow before and after the operation were reviewed angiographically. Results A greater percentage of TIMI 1 flow was archieved in the triofiban+PCI group compared with the primary PCI group before operation (37% vs 9.5%, P0.05). On the other hand, TIMI 0 flow was more commonly found in patients in the primary PCI group compared with the tirofiban+PCI group (38.1% vs 7.4%, P0.01). There was no difference in the archievement of TIMI 3 flow between the two groups after operation, but the occurance of TIMI 2 flow was less in the tirofiban+PCI group compared with the primary PCI group. Conclusion Tirofiban may improve TIMI flow of the IRA in patients with STEMI during primary PCI.
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In patients with acute myocardial infarction (AMI), the off-hour presentation is one of the major determinants of door-to-balloon delay. Moreover, the nighttime presentation is associated with increased mortality after primary coronary intervention (PCI). The prompt starting of a therapy able to start recanalization of the infarct-related artery before intervention might improve the results of off-hour primary PCI. We compared the outcome of 212 consecutive patients with AMI undergoing either direct or facilitated PCI according to the hour of presentation. Patients arriving off-hours were pretreated with alteplase (20 mg) and abciximab and underwent facilitated PCI. Patients presenting on-hours underwent direct PCI. A basal Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 was observed in 1.0% of patients undergoing direct PCI and in 44% of patients undergoing facilitated PCI (P = 0.001). More patients starting PCI with a TIMI 3 flow achieved a postinterventional fast TIMI frame count (72.0% vs. 38.8% direct PCI group vs. 34.9% facilitated PCI group with basal TIMI 0–2; P = 0.001) and a TIMI perfusion grade 3 (66.0% vs. 38.8% direct PCI group vs. 39.7% facilitated PCI group with basal TIMI 0–2; P = 0.004). Preinterventional TIMI flow grade 3 was associated with a higher gain in left ventricular ejection fraction at 1 month (10.9% ± 6.4% vs. 7.0% ± 9.6% direct PCI group vs. 6.1% ± 6.0% facilitated PCI group with basal TIMI 0–2; P = 0.005). No significant difference was observed in major bleedings, although there was a trend toward a higher risk in the facilitated PCI group. Patients in the facilitated PCI group achieving a basal TIMI 3 flow showed improved myocardial reperfusion and better left ventricular function recovery. Bleeding complications associated with combination therapy remained an important concern. © 2005 Wiley-Liss, Inc.
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The 2-year clinical outcomes according to pre-percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) flow grade and reperfusion timing were investigated in patients with non-ST-segment elevation myocardial infarction (NSTEMI) who received newer-generation drug-eluting stents. A total of 7506 NSTEMI patients were divided into 2 groups: early (PCI ≤ 24 hours: n = 6398; pre-PCI TIMI 0/1 [n = 2729], pre-PCI TIMI 2/3 [n = 3669]) and delayed (PCI > 24 hours: n = 1108; pre-PCI TIMI 0/1 [n = 428], pre-PCI TIMI 2/3 [n = 680]) invasive groups. Major adverse cardiac events were defined as all-cause death, recurrent myocardial infarction, or any repeat revascularization. All-cause death (P = 0.005 and 0.009, respectively) and cardiac death (P = .003 and 0.046, respectively) were significantly higher in pre-PCI TIMI 0/1 patients than in pre-PCI TIMI 2/3 patients both in the early and delayed invasive groups. In pre-PCI TIMI 0/1 patients, all-cause death rate was significantly higher in the delayed group (P = .023). In pre-PCI TIMI 2/3 patients, the clinical end point was similar between the 2 groups. An early invasive strategy is preferred to a delayed invasive strategy in reducing all-cause death in patients with pre-PCI TIMI 0/1. However, in patients with pre-PCI TIMI 2/3, both treatment strategies are acceptable.
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Objective To observe the effect of intravenous thrombolysis on TIMI flow of acute myocardial infarction(AMI).Methods A total of 229 patients with AMI analysed retrospectively were divided into two groups:intravenous thrombolysis(IVT)group(n=131)and primary percutaneous coronary intervention(PCI)group(n=98).The treatment time and acute-phase outcomes were compared between the IVT group and the PCI group;104 patients in the IVT group received rescued or delayed PCI(IVT+PCI);TIMI flow was analysed between the IVT+PCI group and the PCI group.Results The time from the emergency room door to initiation of treatment was shorter in the IVT group than in the PCI group(67.79 min vs 134.54 min,P=0.000).At the initial coronary angiography,TIMI 3 flow and TIMI 2+3 flow were higher in the IVT+PCI group than in the PCI group(40.4% vs 24.5%,P=0.016;63.5% vs 36.7%,P=0.000 respectively).There was no significant difference between the IVT group and the PCI group in terms of major adverse cardiac events(MACE).Conclusion IVT as an initial treatment for AMI might achieve earlier reperfusion at TIMI≥2 flow,and it should be popularized in the primary hospitals.
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Objective To compare the effect of time choice on Slow-flow No-reflow(SNR) phenomena in patients with acute myocardial infarction(AMI) who underwent percutaneous coronary intervension(PCI).Methods 272 patients receiving PCI were enrolled.According to TIMI flow,the patients were divided into 2 study populations,who were divided into 3 groups according to immediate PCI or elective PCI,respectively.Results Patients receiving PCI from 24h to one week had more incidence of SNR according to 2 study populations(22/28 vs 8/60,22/28 vs 16/48 P0.05)(14/31 vs 6/62,14/31 vs 4/43,P0.05).Furthermore,patients of immediate PCI had less SNR incidence than those receiving PCI from one week to one month according to TIMI grade 2(8/60 vs 16/48,P0.05).Achievement of TIMI flow grade 3 according to TIMI grade 3 had no significant difference in patients receiving PCI from 24h to one week and those immediate PCI(6/62 vs 4/43,P0.05).Patients receiving PCI from 24h to one week had higher mortality of SNR in TIMI grade 2 group,compared with TIMI grade 3 group(22/28 vs 14/31,P0.05).Conclusion Patients with AMI who underwent immediate PCI had less SNR incidence than those of patients who received elective PCI.
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To identify the risk factors for no-reflow (NR) phenomenon after primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction.A total of 843 patients with AMI underwent primary PCI within 12 h following onset of the ischemic symptoms. According to TIMI flow grade and myocardial blush grade, the patients were divided into reflow group and NR group after primary PCI, and the clinical data, angiography findings and surgical data were compared to analyze the factors contributing to NR.NR occurred in 15.9% of the AMI patients after primary PCI. Univariate analysis showed that previous myocardial infarction, Killip classes of MI, time to reperfusion, IABP use before PCI, TIMI flow grade before primary PCI, long target lesion, pre-PCI thrombus score and method of reperfusion were correlated to NR (P<0.05 ). Multiple logistic analysis identified the time to reperfusion (OR=1.60; 95% CI: 1.02-2.73), TIMI flow grade before primary PCI (OR=1.1; 95% CI: 1.04-1.16), long target lesion (OR=1.40; 95% CI: 1.19-1.69), and pre-PCI thrombus score (OR=2.02; 95% CI: 1.47-2.76) as the independent predictors of NR after primary PCI.The time to reperfusion, TIMI flow grade before primary PCI, long target lesion, and pre-PCI thrombus score are independent predictors of NR after primary PCI for AMI.
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