(Circulation. 2000;101:2332.)
© 2000 American Heart Association, Inc.
Editorials |
Beyond TIMI III Flow
From the Department of Internal Medicine, Division of Cardiology, William Beaumont Hospital, Royal Oak, Mich.
Correspondence to Terry R. Bowers, MD, Department of Internal Medicine, Division of Cardiology, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073.
Key Words: Editorials • blood flow • reperfusion
The Western Washington Intracoronary Streptokinase randomized trial1 first demonstrated that intracoronary thrombolytic therapy improved survival for patients presenting within 12 hours of symptom onset of acute myocardial infarction (MI). Perhaps equally important, this invasive study demonstrated that in-hospital and long-term survival was greatly improved in patients with patent infarct-related arteries.2 These observations ushered in the modern era of reperfusion therapy, and they also firmly established the concept that achieving arterial patency was the predominant mechanism for the prognostic benefit of thrombolytic agents.
Numerous trials since then have validated this open-artery hypothesis.3 4 5 In the early 1990s, Ross et al6 definitively established the relationship between prompt reinstitution of flow, improved myocardial salvage, and survival. Anderson et al7 clearly demonstrated that antegrade flow, as defined by the Thrombolysis in Myocardial Infarction (TIMI) criteria, can differentiate different levels of antegrade flow, with different prognostic implications. Although TIMI flow grades seem to segregate effective from ineffective flow, this analysis is only a qualitative measure that can be subject to bias and interlaboratory variability. Gibson et al8 further refined angiographic flow quantitation using corrected TIMI frame counts. This method of analysis quantitates angiographic contrast velocity measures and decreases variability.
Currently, arterial patency is the gold standard for
assessing the efficacy of different reperfusion protocols. Refinements
in the quantitation of degrees of arterial patency have led
to improvements in the prognostic value of this measure. It has,
however, become increasingly apparent that contrast velocity alone does
not adequately define the level of microvascular perfusion or predict
the
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