Suboptimal Final TIMI Flow After Primary Percutanous Intervention for ST Segment Elevation Myocardial Infarction: Predictors and Impact on Outcome

Abstract

SUMMARY A cute myocardial infarction remains a leading cause of morbidity and mortality worldwide. It occurs when irreversible myocardial cell damage or death occu. ST segment elevation myocardial infarction is the most serious presentation of atherosclerotic coronary artery disease carrying the most hazardous consequences. ST segment elevation myocardial infarction is caused by occlusion of a major coronary artery and primary PCI is the preferred reperfusion strategy especially when performed by an experienced team within the shortest possible time from first medical contact. The benefit of prompt, expertly performed primary percutaneous coronary intervention for acute (STEMI) is now well established. When performed rapidly by an experienced team. Primary PCI improves survival rates in patients with acute myocardial infarction (MI) as compared with thrombolytic therapy, in large part due to better and sustained ante grade epicardial perfusion (thrombolysis in myocardial infarc¬tion [TIMI] grade 3 flow). The current study was conducted on 250 consecutive patients presented to the ER at Ain Shams University Hospitals with acute myocardial infarction between from March 2014 to July 2015. All patients underwent primary PCI. Patients admitted to the coronary care unit were analyzed thoroughly and data was recorded {Full history taking, clinical examination, 12 lead surface ECG, CK total and CK-MB, coronary angiographic details and transthoracic echocardiography in the first 48 hours}. Medical treatment of STEMI after primary PCI was given to subjects as per hospital protocol. All patients were subjected to 7 days, 30 days and 12 months follow up for:  Primary composite point: (MACE) 1- Cardiovascascular death whether from e,g arrhythmia, acute pulmonary oedema 2- Non fatal MI 3- Stroke diagnosed by CT scan, MRI 4- Target vessel revascularization  2ry endpoints: 1- All-cause death whether cardiac or non cardiac 2- Cardiac death 3- non-fatal MI, Stroke 4- Target vessel revascularization 5- Major bleeding (non-CABG related), 6- Definite or probable stent thrombosis. The patients were divided into 2 groups: Group I: included patients which finally TIMI 3 flow after primary PCI (204 patients) Group II: included patients with suboptimal TIMI flow (46 patients) …all patients were contacted by cell phone to give an appointment for the follow up after 12 months In univariate analysis, the suboptimal groups were older than the suboptimal group, in multivariate analysis, age>65 years was a significant predictor for development of suboptimal TIMI flow Both groups were gender matched with homogenous risk factors for CAD except for diabetes mellitus and smoking, in which smoking was more frequent in optimal flow and explained by the smoking paradox phenomena, DM was more frequent in suboptimal flow in univariate analysis and in multivariate analysis was a strong predictor for development of suboptimal TIMI flow At univariate analysis for clinical data, the suboptimal TIMI flow showed longer pain to door time and higher Killip class on admission and multivariate analysis showed that long pain to door time and higher class were significant predictors for development of suboptimal TIMI flow. Meanwhile for coronary angiographic data, univariate analysis showed that use of post dilatation by non compliant balloon was more frequent among suboptimal group, multivariate analysis showed that post dilatation by non compliant balloon was a significant predictor for development of suboptimal TIMI flow. Regarding clinical outcome in during 7 days, after 1 month and 1 year of follow up, the current study showed that suboptimal TIMI flow was associated worse clinical outcome than TIMI 3 flow in the primary end point and secondary endpoint.