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Coronary artery patency and outcome after myocardial infarction

Authors
Richard C Becker, MD
Carey Kimmelstiel, MD
Section Editor
Freek Verheugt, MD, FACC, FESC
Deputy Editor
Gordon M Saperia, MD, FACC

INTRODUCTION

It is widely accepted that the likelihood of death after myocardial infarction (MI) correlates inversely with left ventricular performance. In turn, the degree of left ventricular dysfunction is determined by the extent of myocardial necrosis or infarct size. Thus, pump failure and increased mortality result when the infarct is large and ventricular compromise is severe [1,2].

Prompt and sustained coronary arterial patency has repeatedly been found to limit infarct size. Among patients with an acute ST elevation (Q wave) MI, over 90 percent have complete occlusion of the culprit artery. Patency can be achieved by fibrinolysis, primary percutaneous coronary intervention (PCI), or a combination of both modalities. In addition, there are many factors (hemodynamic, anatomic, cellular) that influence coronary artery patency regardless of the technique used (figure 1). (See "Characteristics of fibrinolytic (thrombolytic) agents and clinical trials in acute ST elevation myocardial infarction" and "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome" and "Primary percutaneous coronary intervention versus fibrinolysis in acute ST elevation myocardial infarction: Clinical trials".)

TIMI FLOW GRADE

The degree of perfusion in the infarct-related artery (IRA) is typically described by the TIMI flow grade:

TIMI 0 refers to the absence of antegrade flow beyond a coronary occlusion.

TIMI 1 flow is faint antegrade coronary flow beyond the occlusion, although filling of the distal coronary bed is incomplete.

                            

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Literature review current through: Nov 2016. | This topic last updated: Mon Sep 21 00:00:00 GMT+00:00 2015.
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References
Top
  1. DeWood MA, Spores J, Notske R, et al. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med 1980; 303:897.
  2. Reiner JS, Lundergan CF, van den Brand M, et al. Early angiography cannot predict postthrombolytic coronary reocclusion: observations from the GUSTO angiographic study. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries. J Am Coll Cardiol 1994; 24:1439.
  3. SALISBURY PF, CROSS CE, RIEBEN PA. Influence of coronary artery pressure upon myocardial elasticity. Circ Res 1960; 8:794.
  4. Connelly CM, Ngoy S, Schoen FJ, Apstein CS. Biomechanical properties of reperfused transmural myocardial infarcts in rabbits during the first week after infarction. Implications for left ventricular rupture. Circ Res 1992; 71:401.
  5. Ono S, Waldman LK, Yamashita H, et al. Effect of coronary artery reperfusion on transmural myocardial remodeling in dogs. Circulation 1995; 91:1143.
  6. Kersschot IE, Brugada P, Ramentol M, et al. Effects of early reperfusion in acute myocardial infarction on arrhythmias induced by programmed stimulation: a prospective, randomized study. J Am Coll Cardiol 1986; 7:1234.
  7. Théroux P, Morissette D, Juneau M, et al. Influence of fibrinolysis and percutaneous transluminal coronary angioplasty on the frequency of ventricular premature complexes. Am J Cardiol 1989; 63:797.
  8. Sager PT, Perlmutter RA, Rosenfeld LE, et al. Electrophysiologic effects of thrombolytic therapy in patients with a transmural anterior myocardial infarction complicated by left ventricular aneurysm formation. J Am Coll Cardiol 1988; 12:19.
  9. Hii JT, Traboulsi M, Mitchell LB, et al. Infarct artery patency predicts outcome of serial electropharmacological studies in patients with malignant ventricular tachyarrhythmias. Circulation 1993; 87:764.
  10. Gang ES, Lew AS, Hong M, et al. Decreased incidence of ventricular late potentials after successful thrombolytic therapy for acute myocardial infarction. N Engl J Med 1989; 321:712.
  11. Aguirre FV, Kern MJ, Hsia J, et al. Importance of myocardial infarct artery patency on the prevalence of ventricular arrhythmia and late potentials after thrombolysis in acute myocardial infarction. Am J Cardiol 1991; 68:1410.
  12. Endoh Y, Kasanuki H, Ohnishi S, et al. Influence of early coronary reperfusion on QT interval dispersion after acute myocardial infarction. Pacing Clin Electrophysiol 1997; 20:1646.
  13. Levy WC, Cerqueira MD, Weaver WD, Stratton JR. Early patency of the infarct-related artery after myocardial infarction preserves diastolic filling. Am J Cardiol 2001; 87:955.
  14. Sheiban I, Fragasso G, Rosano GM, et al. Time course and determinants of left ventricular function recovery after primary angioplasty in patients with acute myocardial infarction. J Am Coll Cardiol 2001; 38:464.
  15. Opitz CF, Finn PV, Pfeffer MA, et al. Effects of reperfusion on arrhythmias and death after coronary artery occlusion in the rat: increased electrical stability independent of myocardial salvage. J Am Coll Cardiol 1998; 32:261.
  16. Llevadot J, Giugliano RP, McCabe CH, et al. Degree of residual stenosis in the culprit coronary artery after thrombolytic administration (Thrombolysis In Myocardial Infarction [TIMI] trials). Am J Cardiol 2000; 85:1409.
  17. Lundergan CF, Reiner JS, McCarthy WF, et al. Clinical predictors of early infarct-related artery patency following thrombolytic therapy: importance of body weight, smoking history, infarct-related artery and choice of thrombolytic regimen: the GUSTO-I experience. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries. J Am Coll Cardiol 1998; 32:641.
  18. de Lemos JA, Antman EM, Giugliano RP, et al. ST-segment resolution and infarct-related artery patency and flow after thrombolytic therapy. Thrombolysis in Myocardial Infarction (TIMI) 14 investigators. Am J Cardiol 2000; 85:299.
  19. Akasaka T, Yoshida K, Kawamoto T, et al. Relation of phasic coronary flow velocity characteristics with TIMI perfusion grade and myocardial recovery after primary percutaneous transluminal coronary angioplasty and rescue stenting. Circulation 2000; 101:2361.
  20. Gibson CM, Ryan KA, Murphy SA, et al. Impaired coronary blood flow in nonculprit arteries in the setting of acute myocardial infarction. The TIMI Study Group. Thrombolysis in myocardial infarction. J Am Coll Cardiol 1999; 34:974.
  21. Menees DS, Peterson ED, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med 2013; 369:901.
  22. Betriu A, Castañer A, Sanz GA, et al. Angiographic findings 1 month after myocardial infarction: a prospective study of 259 survivors. Circulation 1982; 65:1099.
  23. Stone GW, Cox D, Garcia E, et al. Normal flow (TIMI-3) before mechanical reperfusion therapy is an independent determinant of survival in acute myocardial infarction: analysis from the primary angioplasty in myocardial infarction trials. Circulation 2001; 104:636.
  24. De Luca G, Ernst N, Zijlstra F, et al. Preprocedural TIMI flow and mortality in patients with acute myocardial infarction treated by primary angioplasty. J Am Coll Cardiol 2004; 43:1363.
  25. Liebson PR, Klein LW. The non-Q wave myocardial infarction revisited: 10 years later. Prog Cardiovasc Dis 1997; 39:399.
  26. Early effects of tissue-type plasminogen activator added to conventional therapy on the culprit coronary lesion in patients presenting with ischemic cardiac pain at rest. Results of the Thrombolysis in Myocardial Ischemia (TIMI IIIA) Trial. Circulation 1993; 87:38.
  27. Kerensky RA, Wade M, Deedwania P, et al. Revisiting the culprit lesion in non-Q-wave myocardial infarction. Results from the VANQWISH trial angiographic core laboratory. J Am Coll Cardiol 2002; 39:1456.
  28. Wong GC, Morrow DA, Murphy S, et al. Elevations in troponin T and I are associated with abnormal tissue level perfusion: a TACTICS-TIMI 18 substudy. Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction. Circulation 2002; 106:202.
  29. Jang IK, Gold HK, Ziskind AA, et al. Differential sensitivity of erythrocyte-rich and platelet-rich arterial thrombi to lysis with recombinant tissue-type plasminogen activator. A possible explanation for resistance to coronary thrombolysis. Circulation 1989; 79:920.
  30. Mizuno K, Satomura K, Miyamoto A, et al. Angioscopic evaluation of coronary-artery thrombi in acute coronary syndromes. N Engl J Med 1992; 326:287.
  31. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994; 343:311.
  32. Kennedy JW, Ritchie JL, Davis KB, et al. The western Washington randomized trial of intracoronary streptokinase in acute myocardial infarction. A 12-month follow-up report. N Engl J Med 1985; 312:1073.
  33. Vogt A, von Essen R, Tebbe U, et al. Impact of early perfusion status of the infarct-related artery on short-term mortality after thrombolysis for acute myocardial infarction: retrospective analysis of four German multicenter studies. J Am Coll Cardiol 1993; 21:1391.
  34. Becker RC. Late thrombolytic therapy: mechanism of benefit and potential risk among patients treated beyond 6 hours. Coron Artery Dis 1993; 4:293.
  35. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. The GUSTO investigators. N Engl J Med 1993; 329:673.
  36. Holmes DR Jr, Califf RM, Topol EJ. Lessons we have learned from the GUSTO trial. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries. J Am Coll Cardiol 1995; 25:10S.
  37. 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. N Engl J Med 1993; 329:1615.
  38. Newby LK, Rutsch WR, Califf RM, et al. Time from symptom onset to treatment and outcomes after thrombolytic therapy. GUSTO-1 Investigators. J Am Coll Cardiol 1996; 27:1646.
  39. Puma JA, Sketch MH Jr, Thompson TD, et al. Support for the open-artery hypothesis in survivors of acute myocardial infarction: analysis of 11,228 patients treated with thrombolytic therapy. Am J Cardiol 1999; 83:482.
  40. Pomés Iparraguirre H, Conti C, Grancelli H, et al. Prognostic value of clinical markers of reperfusion in patients with acute myocardial infarction treated by thrombolytic therapy. Am Heart J 1997; 134:631.
  41. Anderson JL, Karagounis LA, Becker LC, et al. TIMI perfusion grade 3 but not grade 2 results in improved outcome after thrombolysis for myocardial infarction. Ventriculographic, enzymatic, and electrocardiographic evidence from the TEAM-3 Study. Circulation 1993; 87:1829.
  42. Cigarroa RG, Lange RA, Hillis LD. Prognosis after acute myocardial infarction in patients with and without residual anterograde coronary blood flow. Am J Cardiol 1989; 64:155.
  43. McCully RB, elZeky F, vanderZwaag R, et al. Impact of patency of the left anterior descending coronary artery on long-term survival. Am J Cardiol 1995; 76:250.
  44. Schröder R, Neuhaus KL, Linderer T, et al. Impact of late coronary artery reperfusion on left ventricular function one month after acute myocardial infarction (results from the ISAM study). Am J Cardiol 1989; 64:878.
  45. Galvani M, Ottani F, Ferrini D, et al. Patency of the infarct-related artery and left ventricular function as the major determinants of survival after Q-wave acute myocardial infarction. Am J Cardiol 1993; 71:1.
  46. White HD, Cross DB, Elliott JM, et al. Long-term prognostic importance of patency of the infarct-related coronary artery after thrombolytic therapy for acute myocardial infarction. Circulation 1994; 89:61.
  47. Lamas GA, Flaker GC, Mitchell G, et al. Effect of infarct artery patency on prognosis after acute myocardial infarction. The Survival and Ventricular Enlargement Investigators. Circulation 1995; 92:1101.
  48. Ross AM, Coyne KS, Moreyra E, et al. Extended mortality benefit of early postinfarction reperfusion. GUSTO-I Angiographic Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries Trial. Circulation 1998; 97:1549.
  49. 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 Myocardial Infarction (TIMI) frame count and stenosis severity. Am J Cardiol 1998; 81:665.
  50. Gibson CM, Murphy SA, Rizzo MJ, et al. Relationship between TIMI frame count and clinical outcomes after thrombolytic administration. Thrombolysis In Myocardial Infarction (TIMI) Study Group. Circulation 1999; 99:1945.
  51. Hamada S, Nishiue T, Nakamura S, et al. TIMI frame count immediately after primary coronary angioplasty as a predictor of functional recovery in patients with TIMI 3 reperfused acute myocardial infarction. J Am Coll Cardiol 2001; 38:666.
  52. Abaci A, Oguzhan A, Eryol NK, Ergin A. Effect of potential confounding factors on the thrombolysis in myocardial infarction (TIMI) trial frame count and its reproducibility. Circulation 1999; 100:2219.
  53. Gibson CM, Cannon CP, Murphy SA, et al. Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs. Circulation 2000; 101:125.
  54. Seyfeli E, Abaci A, Kula M, et al. Myocardial blush grade: to evaluate myocardial viability in patients with acute myocardial infarction. Angiology 2007; 58:556.
  55. Nakamura T, Kubo N, Ako J, Momomura S. Angiographic no-reflow phenomenon and plaque characteristics by virtual histology intravascular ultrasound in patients with acute myocardial infarction. J Interv Cardiol 2007; 20:335.
  56. Tanaka A, Shimada K, Namba M, et al. Relationship between longitudinal morphology of ruptured plaques and TIMI flow grade in acute coronary syndrome: a three-dimensional intravascular ultrasound imaging study. Eur Heart J 2008; 29:38.
  57. Zalewski J, Undas A, Godlewski J, et al. No-reflow phenomenon after acute myocardial infarction is associated with reduced clot permeability and susceptibility to lysis. Arterioscler Thromb Vasc Biol 2007; 27:2258.
  58. Bauters C, Delomez M, Van Belle E, et al. Angiographically documented late reocclusion after successful coronary angioplasty of an infarct-related lesion is a powerful predictor of long-term mortality. Circulation 1999; 99:2243.
  59. Brodie BR, Stuckey TD, Wall TC, et al. Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 1998; 32:1312.
  60. Schömig A, Ndrepepa G, Mehilli J, et al. Therapy-dependent influence of time-to-treatment interval on myocardial salvage in patients with acute myocardial infarction treated with coronary artery stenting or thrombolysis. Circulation 2003; 108:1084.
  61. Grzybowski M, Clements EA, Parsons L, et al. Mortality benefit of immediate revascularization of acute ST-segment elevation myocardial infarction in patients with contraindications to thrombolytic therapy: a propensity analysis. JAMA 2003; 290:1891.
  62. Eagle KA, Goodman SG, Avezum A, et al. Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). Lancet 2002; 359:373.
  63. Schömig A, Mehilli J, Antoniucci D, et al. Mechanical reperfusion in patients with acute myocardial infarction presenting more than 12 hours from symptom onset: a randomized controlled trial. JAMA 2005; 293:2865.
  64. Gibbons RJ, Grines CL. Acute PCI for ST-segment elevation myocardial infarction: is later better than never? JAMA 2005; 293:2930.
  65. Clements IP, Christian TF, Higano ST, et al. Residual flow to the infarct zone as a determinant of infarct size after direct angioplasty. Circulation 1993; 88:1527.
  66. Kim CB, Braunwald E. Potential benefits of late reperfusion of infarcted myocardium. The open artery hypothesis. Circulation 1993; 88:2426.
  67. Pizzetti G, Belotti G, Margonato A, et al. Coronary recanalization by elective angioplasty prevents ventricular dilation after anterior myocardial infarction. J Am Coll Cardiol 1996; 28:837.
  68. Elad Y, French WJ, Shavelle DM, et al. Primary angioplasty and selection bias inpatients presenting late (>12 h) after onset of chest pain and ST elevation myocardial infarction. J Am Coll Cardiol 2002; 39:826.
  69. Steg PG, Thuaire C, Himbert D, et al. DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction. Eur Heart J 2004; 25:2187.
  70. Hochman JS, Lamas GA, Buller CE, et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006; 355:2395.
  71. Hochman JS, Reynolds HR, Dzavík V, et al. Long-term effects of percutaneous coronary intervention of the totally occluded infarct-related artery in the subacute phase after myocardial infarction. Circulation 2011; 124:2320.
  72. Dzavík V, Buller CE, Lamas GA, et al. Randomized trial of percutaneous coronary intervention for subacute infarct-related coronary artery occlusion to achieve long-term patency and improve ventricular function: the Total Occlusion Study of Canada (TOSCA)-2 trial. Circulation 2006; 114:2449.
  73. Abbate A, Biondi-Zoccai GG, Appleton DL, et al. Survival and cardiac remodeling benefits in patients undergoing late percutaneous coronary intervention of the infarct-related artery: evidence from a meta-analysis of randomized controlled trials. J Am Coll Cardiol 2008; 51:956.
  74. Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 2008; 117:296.
  75. Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2008; 29:2909.