Primary angioplasty has proven to be the best therapeutic option for acute myocardial infarction AMI , providing early, optimal reestablishment of coronary flow and resulting in a significant reduction in mortality as compared to thrombolytic treatment. In an earlier study we reported that satisfactory myocardial reperfusion, as assessed by noninvasive markers, such as resolution of ST-segment elevation, early T-wave inversion, and time to peak enzyme levels, is associated with a significantly lower risk for heart failure and in-hospital or mid-term mortality in patients with myocardial infarction treated with thrombolysis and primary angioplasty. In this study we prospectively compared the prognostic value of noninvasive indicators of coronary perfusion with TIMI grade 3 flow for the appearance of complications at short- and mid-term in patients with AMI treated by primary angioplasty. Patients with complete bundle branch block or cardiogenic shock were excluded. At emergency room admission, all patients received mg of aspirin and were intravenously treated with heparin to reach an activated coagulation time of approximately s during angioplasty.
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Primary angioplasty has proven to be the best therapeutic option for acute myocardial infarction AMI , providing early, optimal reestablishment of coronary flow and resulting in a significant reduction in mortality as compared to thrombolytic treatment.
In an earlier study we reported that satisfactory myocardial reperfusion, as assessed by noninvasive markers, such as resolution of ST-segment elevation, early T-wave inversion, and time to peak enzyme levels, is associated with a significantly lower risk for heart failure and in-hospital or mid-term mortality in patients with myocardial infarction treated with thrombolysis and primary angioplasty. In this study we prospectively compared the prognostic value of noninvasive indicators of coronary perfusion with TIMI grade 3 flow for the appearance of complications at short- and mid-term in patients with AMI treated by primary angioplasty.
Patients with complete bundle branch block or cardiogenic shock were excluded. At emergency room admission, all patients received mg of aspirin and were intravenously treated with heparin to reach an activated coagulation time of approximately s during angioplasty.
In patients receiving an intracoronary stent, clopidogrel, or ticlopidine was continued for 4 weeks. Beta-blockers and angiotensin-converting enzyme were used in the postinfarction period following the criteria of evidence-based medicine.
Noninvasive Indicators of Myocardial Reperfusion. The electrocardiogram was recorded at baseline and repeated at 90 min. Further electrocardiograms were performed and blood samples were taken for cardiac enzyme determinations at 6, 12, and 24 h of evolution. The electrocardiogram on admission was used as a reference to estimate the magnitude of maximum ST-segment elevation. This was calculated to eight-hundredths of a second after the J point in the lead with the most prominent elevation.
Timing to peak CK value was assessed. Asymptomatic ST-segment re-elevation and positive T-wave within 24 hours after the procedure were also considered criteria of failed reperfusion.
In keeping with the TIMI group classification, post-angioplasty coronary flow was classified into grade 0, absence of flow beyond the occlusion, grade 1, contrast opacification of the coronary artery, but without distal filling, grade 2, slow opacification of the entire coronary artery and grade 3, normal coronary flow. Cardiovascular events at 6 months' evolution follow-up by direct clinical visits, consultation with attending physicians or by telephone : death, development of heart failure, rehospitalization due to heart failure, and recurrent angina.
For the univariate analysis we used the chi-square test and the Fisher exact test to compare categorical variables. Continuous variables were analyzed with the Student t test. Agreement between noninvasive reperfusion and successful angioplasty was analyzed using the Kappa index. The multivariate analysis of in-hospital events death, heart failure, atrial fibrillation, atrioventricular block, or ventricular tachycardia and mid-term complications development of heart failure, hospitalization for heart failure, or recurrent angina was carried out by logistic regression.
In addition, a multivariate analysis was performed to independently analyze only TIMI 3 flow or only successful reperfusion with the other confounding variables. The Cox proportional hazards model was used for the analysis of mid-term mortality.
Successful reperfusion according to the noninvasive markers was present in Table 1 shows the demographic, clinical and angiographic characteristics of the patients. A total of patients had both TIMI 3 flow and successful reperfusion, but the Kappa index was only 0. Tables 2 and 3 show the characteristics of the patients according to TIMI 3 flow or successful reperfusion. There was a significantly higher percentage of cases of anterior infarction among the patients with failed perfusion.
In-hospital mortality. In-hospital mortality was 3. Table 4 shows the results of the independent analysis of TIMI 3 flow and successful reperfusion; both criteria are confirmed to be significant protectors against in-hospital mortality. In-hospital heart failure. Among the total, When TIMI 3 flow and successful reperfusion were analyzed independently, the significant protection by the latter was confirmed Table 4.
In-hospital development of atrial fibrillation, ventricular tachycardia, or second- or third-degree atrioventricular block. The incidence of these alterations was Nevertheless, when the two variables were introduced independently in the multivariate analysis, we found that both TIMI 3 flow and noninvasive indicators were significantly protective against the development of these complications.
There were no differences in the clinical characteristics of the patients who completed their follow-up and those in whom this information was not obtained because of a loss of contact with our institution. Overall mortality at mid-term was 7. All together, these events presented in These results were associated with low mortality, a finding that is consistent with the results reported in other series of patients treated with primary angioplasty.
Nevertheless, only successful myocardial reperfusion was found to be protective against the development of heart failure, complex cardiac arrhythmias, and mortality at mid-term.
Various clinical studies have demonstrated that successful reestablishment of coronary circulation, whether by thrombolysis or angioplasty, depends on achieving optimum coronary tissue reperfusion and microcirculation. In later studies using other noninvasive methods, such as magnetic resonance imaging and myocardial 99 Tc-sestamibi single-photon emission computed tomography, in addition to contrast echocardiography, various authors have confirmed this finding. The noninvasive method most often used to assess myocardial reperfusion has been evaluation of the decrease in ST-segment elevation in the electrocardiographic leads corresponding to the area of the infarction.
Because of the simplicity of the method, ST resolution has been incorporated in routine clinical practice as a relevant part of the evaluation of outcome in multicenter clinical trials. ST-segment resolution assessed by electrocardiograms performed within a fixed period has limitations. Shah et al 28 described ST-segment fluctuations after thrombolysis, and these findings were later confirmed by Krucoff et al using continuous monitoring by digital echocardiography.
Among the limitations of the method proposed is the fact that the diagnosis of successful or failed perfusion is established late relative to the implementation of primary angioplasty. In this regard, it might be useful to monitor the resolution of ST-segment elevation sequentially in order to assess its stability and to determine whether it is followed by cardiac enzyme and T-wave changes.
An attractive but more sophisticated technique has been proposed by Krucoff et al, 30 who used continuous ST-segment monitoring by digital echocardiography. This method achieved a high degree of sensitivity and specificity when establishing myocardial reperfusion and the prognosis. Another limitation of our study is that the only angiographic variable assessed was TIMI 3 flow. It is likely that if other variables such as the TIMI frame count and myocardial blush grade had been incorporated into the analysis, a higher degree of agreement with noninvasive methods would have been achieved.
In summary, noninvasive methods derived from the echocardiogram and enzyme panel allowed establishment of the short- and mid-term prognosis in patients treated with primary angioplasty. Moreover, this method was superior and complementary to the degree of coronary recanalization determined on coronary arteriography by TIMI 3 flow.
The use of noninvasive markers of myocardial reperfusion has greater prognostic value than TIMI 3 flow in patients undergoing coronary angioplasty, and should be used together with the angiographic method to provide additional data. Correspondence: Dr. Marcoleta E-mail: corbalan med. Descargar PDF. TABLE 1. TABLE 2. TABLE 4. Introduction and objectives. The aim of this study was to compare the prognostic value of TIMI 3 flow versus noninvasive markers of coronary artery reperfusion on the outcome of patients with a recent acute myocardial infarction AMI treated with primary angioplasty.
Patients and method. We analyzed consecutive patients with AMI and ST-segment elevation, who were treated with primary angioplasty within 12 hours of admission. The noninvasive criterion for successful reperfusion was the presence of two or more markers of reperfusion based on ECG changes or CK levels after angioplasty. Reperfusion was successful in However, in the multivariate analysis only successful reperfusion was a protective factor for heart failure and complex arrhythmias.
Our findings confirm that both TIMI 3 flow and successful coronary reperfusion evaluated noninvasively show independent prognostic value in patients with AMI treated with primary angioplasty. Noninvasive markers of coronary reperfusion should be used as complementary to angiography in these patients.. Myocardial infarction. Palabras clave:. Infarto de miocardio. Texto completo. Criteria of Successful Angioplasty and TIMI Coronary Flow In keeping with the TIMI group classification, post-angioplasty coronary flow was classified into grade 0, absence of flow beyond the occlusion, grade 1, contrast opacification of the coronary artery, but without distal filling, grade 2, slow opacification of the entire coronary artery and grade 3, normal coronary flow.
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ILCOR: manejo inicial del Síndrome Coronario Agudo: Revisión y cambios
La enfermedad arterial coronaria y particularmente el infarto agudo de miocardio IAM son las principales causas de muerte y discapacidad a nivel mundial. Thrombus aspiration during ST segment elevation myocardial infarction. N Engl J Med. Randomized trial of primary PCI with and without routine manual thrombectomy.
Valor del diagnóstico clínico precoz a través del electrocardiograma