Grzegorz J. Horszczaruk

TIMI Myocardial Perfusion Grade and ST-segment resolution in the assessment of coronary reperfusion after primary angioplasty

BACKGROUND Angiographic coronary flow parameters and resolution of ST segment changes play an important role in the evaluation of reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI). In previous studies on the relation between angiographic and electrocardiographic (ECG) parameters of coronary reperfusion, several alternative methods to assess ST segment resolution were used. Thus, the relation between the TIMI Myocardial Perfusion Grade (TMPG) and different methods to evaluate ST segment resolution seems to be of interest. AIM To evaluate the relationship between TMPG and absolute and relative ST segment resolution after successful primary percutaneous coronary intervention (pPCI). METHODS We studied a population of STEMI patients successfully treated with pPCI. Reperfusion of the coronary microcirculation was determined using 4-grade TMPG scale in coronary angiography performed after successful pPCI. ST segment resolution was analysed in two manners: 1) by calculating the sum of ST segment elevation in infarct leads and depression in reciprocal leads after pPCI (absolute resolution, SSTD); 2) as a percent reduction of summed ST segment deviation from the baseline value (relative resolution, SSTD%). Maximum ST segment elevation in a single lead on the postprocedural ECG was measured to categorise the risk of death. ST segment elevation > 1 mm for an inferior infarct or > 2 mm for an anterior infarct was considered the criterion of high risk (high risk ECG). RESULTS The study population included 183 patients treated with pPCI. We found a significant but weak negative correlation between TMPG and SSTD (r = -0.27, p = 0.0002). Significant differences in median SSTD were observed between TMPG 0 vs. TMPG 2 and TMPG 3 groups (p = 0.0034 and 0.0121, respectively) and also between TMPG 1 and TMPG 2 (p = 0.02). A significant but very weak positive correlation was found between TMPG and SSTD% (r = 0.16,p = 0.0286). However, further analyses showed that differences in median SSTD% between patients with different TMPG values were statistically insignificant (p = 0.1756). In patients with TMPG 2/3, a high risk ECG was absent considerably more often (p = 0.0007). However, angiographic features of successfully vs. unsuccessfully reperfused microcirculation did not correspond to the presence of a high risk ECG in about 34% of cases. CONCLUSIONS TMPG is more closely related to absolute compared to relative ST segment resolution. A high risk ECG was absent in most patients with TMPG 2 or 3. However, in about one third of cases TMPG did not correspond to the presence of ECG high risk features. These data suggest that TMPG is complementary to ST segment resolution in the assessment of coronary reperfusion.

A case of discordance between fractional and coronary flow reserve in functional assessment of an isolated left anterior descending artery lesion

Address for correspondence: Grzegorz J. Horszczaruk, MD, PhD, Catheterisation Laboratory, Miedzyleski Specialist Hospital, ul. Bursztynowa 2, 04–749 Warszawa, Poland, e-mail: horhor@wp.pl Conflict of interest: none declared Kardiologia Polska Copyright

826-4 B-type natriuretic peptide levels on admission predict short-term mortality and angiographic success of procedure in patients with acute ST elevation myocardial infarction treated with primary angioplasty

Background: B-type natriuretic peptide (BNP) levels in the first days after the onset of symptoms are predictive of short-term mortality in patients with acute coronary syndromes. Few data are available for BNP levels obtained on admission in patients (pts) with acute ST elevation myocardial infarction (STEMI). Methods: Blood samples for BNP determination were obtained on admission in 117 pts (mean age 58,4±10,7 years old) with STEMI. In a 15-minute period, BNP was measured by using simple bedside test for rapid quantification of BNP, before primary percutaneus coronary intervention (PCI). 30 days follow-up was performed. PCI was performed in all (100%) pts. Results: Mean for BNP was 171,8±218,2 pg/ml. Baseline level of BNP was higher among pts who died than among those who were alive at 30 days (median, 541,9±247,2pg/ml vs. 140,9±185,9 pg/ ml; p<0,001). Baseline BNP in subgroups by median level showed a significant increase in mortality: 1 (1%) in inframedian group (IMG) vs. 8 (13%) in supramedian group (SMG) (p<0,05). Baseline level of BNP in subgroups by Killip class on admission was higher among pts who died than among those who were alive at 30 days (Killip class I: median, 475,8± 280,6 pg/ml vs. 123,6±138,1 pg/ml p<0,05; Killip class II-IV: 257,1± 362,5 pg/ml vs. 624,5± 203,9 pg/ml, p=0,01). After adjustment for independent predictors of risk of death, the odds ratio for death at 30 days in SMG was 13,6 (95% confidence interval, 1.1 to 182.7). There was no difference in subgroups by median BNP in TIMI 3 flow grade before PCI (7% vs. 7%; p=NS). TIMI 3 after PCI was more often seen in pts in IMG vs. SMG (90% vs. 72%, p=0,01). BNP was higher among pts with TIMI 0, 1 or 2 after PCI than among pts with TIMI 3 after PCI (328,3±332,8 pg/ml vs. 151,32±196,7 pg/ml; p<0,01). BNP remained independent predictor for TIMI 0, 1 or 2 after PCI (odds ratio in SMG was 3,5 (95% confidence interval 1,2 to 10,8). Conclusion: BNP levels obtained on admission are powerful, independent indicator of short-term mortality and angiographic success after PCI in pts with STEMI. Rapid tests for BNP assay seem to be new tool in risk stratification of pts with STEMI.