Abstract
Unfavorable hemodynamics among patients with ST-elevation myocardial infarction (STEMI) have been associated with adverse clinical outcomes and may be linked to a failure to achieve complete reperfusion. We hypothesized that impaired epicardial and tissue-level perfusion after fibrinolytic therapy would be associated with adverse hemodynamics. The relationship between left ventricular end-diastolic pressure (LVEDP), baseline clinical characteristics, and angiographic findings were examined in 666 patients with STEMI treated with fibrinolytic therapy from the TIMI 14, INTEGRITI (TIMI 20), ENTIRE (TIMI 23), and FASTER (TIMI 24) trials. LVEDP was analyzed as a dichotomous variable with an elevated LVEDP defined as LVEDP >18 mmHg (median value). Higher post-fibrinolytic LVEDP was associated with age ≥65, female gender, Killip Class II–IV on presentation, and LAD culprit location. Elevated LVEDP was associated with both a closed infarct-related artery (58.8% of TIMI Flow Grade (TFG) 0/1 with elevated LVEDP vs. 46.6% of TFG 2/3, p = 0.03) and impaired myocardial perfusion (55.7% of TIMI Myocardial Perfusion Grade (TMPG) 0/1 with elevated LVEDP vs. 43.8% of TMPG 2/3, p = 0.02). In a multivariate analysis, impaired myocardial perfusion (OR 1.7, p = 0.02), abnormal Killip Class (OR 4.8, p = 0.001), age ≥65 (OR 1.6, p = 0.04), and female gender (OR 1.9, p = 0.01) were independently associated with elevated LVEDP. Elevated LVEDP was independently associated with a greater incidence of in-hospital (OR 11.8, p = 0.02) and 30-day congestive heart failure (OR 4.4, p = 0.02). In STEMI, angiographic indices of incomplete reperfusion are associated with an elevated LVEDP, and elevated LVEDP is associated with adverse clinical outcomes.
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References
Hillis LD, Braunwald E. Myocardial ischemia (first of three parts). N Engl J Med 1977;296:971–978.
Rackley CE, Russell RO, Jr. Left ventricular function in acute and chronic coronary artery disease. Annu Rev Med 1975;26:105–120.
Cohn JN. Left ventricular function after myocardial infarc-tion. J Cardiovasc Pharmacol 1989;14(Suppl 9):S55–S58.
Poulsen SH, Moller JE, Norager B, Egstrup K. Prognostic implications of left ventricular diastolic dysfunction with preserved systolic function following acute myocardial in-farction. Cardiology 2001;95:190–197.
Cerisano G, Bolognese L, Buonamici P, et al. Prognostic implications of restrictive left ventricular filling in reper-fused anterior acute myocardial infarction. J AmColl Car-diol 2001;37:793–799.
Forrester JS, Diamond G, Chatterjee K, Swan HJ. Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). N Engl J Med 1976;295:1356–1362.
Forrester JS, Diamond G, Chatterjee K, Swan HJ. Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). N Engl J Med 1976;295:1404–1413.
Gibson CM, Goel M, Murphy SA, et al. Global impair-ment of coronary blood flow in the setting of acute coronary syndromes (a RESTORE substudy). Randomized Efficacy Study of Tirofiban for Outcomes and Restenosis. Am J Car-diol 2000;86:1375–1377, A5.
French JK, Ellis CJ, Webber BJ, et al. Abnormal coronary flow in infarct arteries 1 year after myocardial infarction is predicted at 4 weeks by corrected Thrombolysis in Myocar-dial Infarction (TIMI) frame count and stenosis severity. Am J Cardiol 1998;81:665–671.
Ito H, Okamura A, Iwakura K, et al. Myocardial perfusion patterns related to thrombolysis in myocardial infarction perfusion grades after coronary angioplasty in patients with acute anterior wall myocardial infarction. Circulation 1996;93:1993–1999.
Gibson CM, Cannon CP, Murphy SA, et al. Relationship of TIMI myocardial perfusion grade to mortality after admin-istration of thrombolytic drugs. Circulation 2000;101:125–130.
Antman EM, Giugliano RP, Gibson CM, et al. Abciximab facilitates the rate and extent of thrombolysis: Results of the thrombolysis in myocardial infarction (TIMI) 14 trial. The TIMI 14 Investigators. Circulation 1999;99:2720–2732.
Giugliano RP, Roe MT, Harrington RA, et al. Combina-tion reperfusion therapy with eptifibatide and reduced-dose tenecteplase for ST-elevation myocardial infarction: Results of the integrilin and tenecteplase in acute myocar-dial infarction (INTEGRITI) Phase II Angiographic Trial. J AmColl Cardiol 2003;41:1251–1260.
Antman EM, Louwerenburg HW, Baars HF, et al. Enoxaparin as adjunctive antithrombin therapy for ST-elevation myocardial infarction: Results of the ENTIRE-Thrombolysis in Myocardial Infarction (TIMI) 23 Trial. Circulation 2002;105:1642–1649.
Gibson CM, Cannon CP, Daley WL, et al. TIMI frame count: A quantitative method of assessing coronary artery flow. Circulation 1996;93:879–888.
The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. TIMI Study Group. N Engl J Med 1985; 312:932–936.
Stata Statistical Software. College Station, TX: Stata Cor-poration, 2000.
Angeja BG, Gunda M, Murphy SA, et al. TIMI my-ocardial perfusion grade and ST segment resolution: As-sociation with infarct size as assessed by single pho-ton emission computed tomography imaging. Circulation 2002;105:282–285.
Dibra A, Mehilli J, Dirschinger J, et al. Thrombolysis in myocardial infarction myocardial perfusion grade in angiography correlates with myocardial salvage in pa-tients with acute myocardial infarction treated with stent-ing or thrombolysis. J AmColl Cardiol 2003;41:925–929.
Kunichika H, Katayama K, Sakai H, Yonezawa T, Matsuzaki M. The effect of left ventricular chamber com-pliance on early diastolic filling during coronary reperfu-sion. Jpn Circ J 1995;59:762–771.
Kloner RA, Ellis SG, Carlson NV, Braunwald E. Coro-nary reperfusion for the treatment of acute myocardial.184 Kirtane et al. infarction: Postischemic ventricular dysfunction. Cardiol-ogy 1983;70:233–246.
Ito H, Tomooka T, Sakai N, et al. Lack of myocardial perfu-sion immediately after successful thrombolysis. A predic-tor of poor recovery of left ventricular function in anterior myocardial infarction. Circulation 1992;85:1699–1705.
Roe MT, Ohman EM, Maas AC, et al. Shifting the open-artery hypothesis downstream: The quest for optimal reperfusion. J AmColl Cardiol 2001;37:9–18.
Doi Y, Masuyama T, Yamamoto K, et al. Coronary back flow pressure is elevated in association with increased left ventricular end-diastolic pressure in humans. Angiology 1996;47:1047–1051.
Klocke FJ, Mates RE, Canty JM, Jr, Ellis AK. Coro-nary pressure-flow relationships. Controversial issues and probable implications. Circ Res 1985;56:310–323.
Permutt S, Riley RL. Hemodynamics of collapsible ves-sels with tone: The vascular waterfall. J Appl Physiol 1963;18:924–932.
Hoffman JI, Spaan JA. Pressure-flow relations in coronary circulation. Physiological Reviews 1990;70:331–390.
Ito H, Iwakura K, Oh H, et al. Temporal changes in my-ocardial perfusion patterns in patients with reperfused an-terior wall myocardial infarction. Their relation to myocar-dial viability. Circulation 1995;91:656–662.
Woodfield SL, Lundergan CF, Reiner JS, et al. Gender and acute myocardial infarction: Is there a different response to thrombolysis? J AmColl Cardiol 1997;29:35–42.
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Kirtane, A.J., Bui, A., Murphy, S.A. et al. Association of Epicardial and Tissue-Level Reperfusion with Left Ventricular End-Diastolic Pressures in ST-Elevation Myocardial Infarction. J Thromb Thrombolysis 17, 177–184 (2004). https://doi.org/10.1023/B:THRO.0000040486.10549.f6
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DOI: https://doi.org/10.1023/B:THRO.0000040486.10549.f6