Circulation, Vol 88, 1527-1533, Copyright © 1993 by American Heart Association
IP Clements, TF Christian, ST Higano, RJ Gibbons and BJ Gersh
BACKGROUND. In acute myocardial infarction, residual flow to the infarct
zone either through antegrade flow in the infarct-related coronary artery
or collateral flow from the non-infarct-related arteries is often present
before reperfusion therapy. The purpose of this study was to assess the
influence of antegrade flow in the infarct- related artery and/or
collateral flow to the infarct zone before successful direct angioplasty on
infarct size and myocardial salvage in patients with acute evolving
myocardial infarction. METHODS AND RESULTS. Sixty patients with acute
evolving myocardial infarction underwent direct successful angioplasty
without prior thrombolytic therapy. The myocardium at risk of infarction,
the final infarct size, and myocardial salvage were measured by tomographic
perfusion imaging with 99mTc sestamibi. Antegrade flow in the
infarct-related artery before intervention was graded according to the
Thrombolysis in Myocardial Infarction (TIMI) study group classification.
Collateral flow to the infarct zone before angioplasty was also graded (0
through 3, 0 being no collateral flow). The presence of even minimal
antegrade flow before angioplasty (TIMI grade 1) in the infarct-related
artery compared with absent flow was associated with a significant
reduction in final infarct size (9 +/- 17% versus 23 +/- 19% of left
ventricle, P = .02) and a significant increase in myocardial salvage (23
+/- 16% versus 14 +/- 13% of left ventricle, P = .05) after angioplasty.
When antegrade flow in the infarct-related artery was absent before
angioplasty, the presence of collateral flow before angioplasty resulted in
a significantly smaller final infarct size (P = .01) and more myocardial
salvage (P = .05) after angioplasty. Both antegrade infarct-related artery
flow and collateral flow to the infarct zone had significant independent
ability to predict infarct size after angioplasty. When collateral grade
and TIMI grade were added to provide an estimate of residual flow, a model
including residual flow, myocardium at risk, and the interaction of
residual flow and infarct site explained 83% of the variability in infarct
size after angioplasty. CONCLUSIONS. The presence of antegrade flow in the
infarct- related artery and/or collateral flow to the infarct zone before
direct angioplasty in acute evolving infarction results in a smaller
infarct size after direct successful angioplasty.
ARTICLES
Residual flow to the infarct zone as a determinant of infarct size after direct angioplasty
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minn. 55905.
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