Suboptimal reperfusion after primary percutaneous coronary intervention in acute ST elevation myocardial infarction
- C Michael Gibson, MS, MD
C Michael Gibson, MS, MD
- Professor of Medicine
- Harvard Medical School
- Joseph P Carrozza, MD
Joseph P Carrozza, MD
- Vice President
- Steward Cardiovascular Network
- Professor of Medicine
- Tufts University School of Medicine
- Roger J Laham, MD
Roger J Laham, MD
- Associate Professor of Medicine
- Harvard Medical School
Coronary reperfusion after acute ST-elevation myocardial infarction (STEMI) improves patient outcomes. This can be achieved by primary percutaneous coronary intervention (PCI), usually with stenting, or fibrinolytic therapy. Primary PCI is preferred if it can be performed (door-to-balloon time) within 90 to 120 minutes of presentation to the hospital because of greater efficacy in achieving coronary perfusion and better clinical outcomes. (See "Primary percutaneous coronary intervention versus fibrinolysis in acute ST elevation myocardial infarction: Clinical trials", section on 'Primary PCI versus fibrinolytic trials'.)
The efficacy of revascularization with primary PCI can be assessed using the Thrombolysis in Myocardial Infarction (TIMI) flow grading system (originally developed to assess reperfusion after fibrinolysis) (table 1). Trials of fibrinolytic therapy have shown that the clinical benefits of reperfusion correlate with the restoration of TIMI grade 3 (normal) epicardial coronary flow (figure 1A-B), which is only attained in 50 to 60 percent of patients [1-5]. (See "Fibrinolytic (thrombolytic) agents in acute ST elevation myocardial infarction: Markers of efficacy", section on 'TIMI flow grade'.)
Attainment of TIMI 3 flow is much more common with primary PCI, being achieved in 93 to 96 percent in the PAMI and CADILLAC trials of more than 5400 patients [6,7]. However, some patients do not recover normal epicardial flow despite the absence of vessel obstruction. This phenomenon is called no-reflow and is a predictor of worse outcome. (See 'No-reflow phenomenon' below.)
Issues related to suboptimal reperfusion after primary PCI will be reviewed here. Other issues related to primary PCI and the clinical use of fibrinolytic therapy are discussed separately. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome" and "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy".)
Suboptimal reperfusion after primary percutaneous coronary intervention (PCI) may be caused by one or more of several factors, including:
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- RISK FACTORS
- NO-REFLOW PHENOMENON
- - Thrombectomy
- - Distal embolic protection devices
- - Direct stenting
- - Systemic GP IIb/IIIa inhibitors
- - Intracoronary infusions
- Vasodilator therapies
- Antithrombotic/thrombolytic therapies
- - Chronic statin therapy
- SUMMARY AND RECOMMENDATIONS