Journal of Thrombosis and Thrombolysis

, Volume 27, Issue 2, pp 123–129 | Cite as

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

  • Evan Appelbaum
  • Ajay J. Kirtane
  • Alicia Clark
  • Yuri B. Pride
  • Eli V. Gelfand
  • Caitlin J. Harrigan
  • Kraig V. Kissinger
  • Warren J. Manning
  • C. Michael Gibson
Article

Abstract

Background Impairment of coronary microvascular perfusion is common among patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Cardiovascular magnetic resonance imaging (CMR) can identify microvascular obstruction (MO) following reperfusion of STEMI. We hypothesized that myocardial perfusion, as assessed by the Thrombolysis in Myocardial Infarction (TIMI) Myocardial Perfusion Grade (TMPG), would be associated with a CMR metric of MO in this population. Methods Twenty-one STEMI patients who underwent successful primary PCI were evaluated. Contrast-enhanced CMR was performed within 7 days of presentation and repeated at three months. TIMI Flow Grade (TFG), corrected TIMI Frame Count (cTFC), TMPG, MO, infarct size, and left ventricular ejection fraction (EF) were assessed. Results The median peak creatine phosphokinase (CPK) was 1,775 IU/l (interquartile range 838–3,321). TFG 3 was present following PCI in 19 (90%) patients. CMR evidence of MO was present in 52% following PCI. Abnormal post-PCI TMPG (0/1/2) was present in 48% of subjects and was associated with MO on CMR (90% MO with TMPG 0/1/2 vs. 18% MO with TMPG 3, P < 0.01). Abnormal post-PCI TMPG was also associated with a greater peak CK (median 3,623 IU/l vs. 838 IU/l, P < 0.001) and greater relative infarct size (17.3% vs. 5.2%, P < 0.01). Conclusion Among STEMI patients undergoing primary PCI, post-PCI TMPG correlates with CMR measures of MO and infarct size. The combined use of both metrics in a comprehensive assessment of microvascular integrity and infarct size following STEMI may aid in the evaluation of future therapeutic strategies.

Keywords

Microvascular obstruction ST-segment elevation myocardial infarction TIMI Myocardial Perfusion Grade Cardiovascular magnetic resonance Primary percutaneous coronary intervention 

Notes

Acknowledgments

Funding sources: Supported in part by grants from American College of Cardiology Foundation/Merck Adult Cardiology Research Fellowship Award and the Harvard/Massachusetts Institute of Technology/Pfizer, Merck Clinical Investigator Training Program.

References

  1. 1.
    The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. TIMI Study Group (1985) N Engl J Med 312(14):932–936Google Scholar
  2. 2.
    The effects of tissue plasminogen activator, streptokinase, or both on coronary–artery patency, ventricular function, and survival after acute myocardial infarction. The GUSTO Angiographic Investigators (1993) N Engl J Med 329(22):1615–1622Google Scholar
  3. 3.
    Ellis SG et al (1994) Randomized comparison of rescue angioplasty with conservative management of patients with early failure of thrombolysis for acute anterior myocardial infarction. Circulation 90(5):2280–2284PubMedGoogle Scholar
  4. 4.
    Angeja BG et al (2002) TIMI myocardial perfusion grade and ST segment resolution: association with infarct size as assessed by single photon emission computed tomography imaging. Circulation 105(3):282–285PubMedCrossRefGoogle Scholar
  5. 5.
    Antman EM et al (2002) Determinants of improvement in epicardial flow and myocardial perfusion for ST elevation myocardial infarction; insights from TIMI 14 and InTIME-II. Eur Heart J 23(12):928–933PubMedCrossRefGoogle Scholar
  6. 6.
    Appleby MA et al (2001) Angiographic assessment of myocardial perfusion: TIMI myocardial perfusion (TMP) grading system. Heart 86(5):485–486PubMedCrossRefGoogle Scholar
  7. 7.
    Gibson CM et al (2002) Relationship of creatine kinase-myocardial band release to thrombolysis in myocardial infarction perfusion grade after intracoronary stent placement: an ESPRIT substudy. Am Heart J 143(1):106–110PubMedCrossRefGoogle Scholar
  8. 8.
    Gibson CM et al (1999) Relationship between TIMI frame count and clinical outcomes after thrombolytic administration. Thrombolysis in Myocardial Infarction (TIMI) Study Group. Circulation 99(15):1945–1950PubMedGoogle Scholar
  9. 9.
    Kirtane AJ et al (2006) Angiographically evident thrombus following fibrinolytic therapy is associated with impaired myocardial perfusion in STEMI: a CLARITY-TIMI 28 substudy. Eur Heart J 27(17):2040–2045PubMedCrossRefGoogle Scholar
  10. 10.
    Gibson CM et al (2000) Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs. Circulation 101(2):125–130PubMedGoogle Scholar
  11. 11.
    Taylor AJ et al (2004) Detection of acutely impaired microvascular reperfusion after infarct angioplasty with magnetic resonance imaging. Circulation 109(17):2080–2085PubMedCrossRefGoogle Scholar
  12. 12.
    Wu KC et al (1998) Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation 97(8):765–772PubMedGoogle Scholar
  13. 13.
    Grothues F et al (2002) Comparison of interstudy reproducibility of cardiovascular magnetic resonance with two-dimensional echocardiography in normal subjects and in patients with heart failure or left ventricular hypertrophy. Am J Cardiol 90(1):29–34PubMedCrossRefGoogle Scholar
  14. 14.
    Ingkanisorn WP et al (2004) Gadolinium delayed enhancement cardiovascular magnetic resonance correlates with clinical measures of myocardial infarction. J Am Coll Cardiol 43(12):2253–2259PubMedCrossRefGoogle Scholar
  15. 15.
    Kim RJ et al (2000) The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 343(20):1445–1453PubMedCrossRefGoogle Scholar
  16. 16.
    Gibson CM et al (1996) TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation 93(5):879–888PubMedGoogle Scholar
  17. 17.
    Kim RJ et al (1999) Relationship of elevated 23Na magnetic resonance image intensity to infarct size after acute reperfused myocardial infarction. Circulation 100(2):185–192PubMedGoogle Scholar
  18. 18.
    Zmudka K et al (2004) The degree of restored myocardial perfusion in acute myocardial infarction influences immediate and long-term results of primary coronary angioplasty. Kardiol Pol 61(10):316–27; discussion 327–328PubMedGoogle Scholar
  19. 19.
    Porto I et al (2007) Relation of myocardial blush grade to microvascular perfusion and myocardial infarct size after primary or rescue percutaneous coronary intervention. Am J Cardiol 99(12):1671–1673PubMedCrossRefGoogle Scholar
  20. 20.
    Michaels AD, Gibson CM, Barron HV (2000) Microvascular dysfunction in acute myocardial infarction: focus on the roles of platelet and inflammatory mediators in the no-reflow phenomenon. Am J Cardiol 85(5A):50B–60BPubMedCrossRefGoogle Scholar
  21. 21.
    Aletras AH et al (2006) Retrospective determination of the area at risk for reperfused acute myocardial infarction with T2-weighted cardiac magnetic resonance imaging: histopathological and displacement encoding with stimulated echoes (DENSE) functional validations. Circulation 113(15):1865–1870PubMedCrossRefGoogle Scholar
  22. 22.
    Baks T et al (2006) Multislice computed tomography and magnetic resonance imaging for the assessment of reperfused acute myocardial infarction. J Am Coll Cardiol 48(1):144–152PubMedCrossRefGoogle Scholar
  23. 23.
    Porto I et al (2006) Plaque volume and occurrence and location of periprocedural myocardial necrosis after percutaneous coronary intervention: insights from delayed-enhancement magnetic resonance imaging, thrombolysis in myocardial infarction myocardial perfusion grade analysis, and intravascular ultrasound. Circulation 114(7):662–669PubMedCrossRefGoogle Scholar
  24. 24.
    Tarantini G et al (2005) Duration of ischemia is a major determinant of transmurality and severe microvascular obstruction after primary angioplasty: a study performed with contrast-enhanced magnetic resonance. J Am Coll Cardiol 46(7):1229–1235PubMedCrossRefGoogle Scholar
  25. 25.
    Schroeder AP et al (2001) Serial magnetic resonance imaging of global and regional left ventricular remodeling during 1 year after acute myocardial infarction. Cardiology 96(2):106–114PubMedCrossRefGoogle Scholar
  26. 26.
    Aasa M et al (2007) Temporal changes in TIMI myocardial perfusion grade in relation to epicardial flow, ST-resolution and left ventricular function after primary percutaneous coronary intervention. Coron Artery Dis 18(7):513–518PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Evan Appelbaum
    • 1
    • 2
  • Ajay J. Kirtane
    • 1
    • 2
  • Alicia Clark
    • 3
  • Yuri B. Pride
    • 3
  • Eli V. Gelfand
    • 1
  • Caitlin J. Harrigan
    • 2
  • Kraig V. Kissinger
    • 1
  • Warren J. Manning
    • 1
  • C. Michael Gibson
    • 1
    • 2
  1. 1.Division of Cardiovascular Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.TIMI Data Coordinating CenterPERFUSE Core LaboratoriesBostonUSA
  3. 3.Department of Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA

Personalised recommendations