In the setting of ST-segment elevation myocardial infarction (STEMI), the Thrombolysis In Myocardial Infarction (TIMI) risk score(TRS) and indexes of epicardial and myocardial perfusion are associated with mortality. ...In the setting of ST-segment elevation myocardial infarction (STEMI), the Thrombolysis In Myocardial Infarction (TIMI) risk score(TRS) and indexes of epicardial and myocardial perfusion are associated with mortality. The association between TRS at presentation and angiographic indexes of epicardial and myocardial perfusion after reperfusion therapy has not been investigated. We hypothesized that TRS, TIMI flow grade(TFG), and TIMI myocardial perfusion grade(TMPG) would provide independent prognostic information and that angiographic indexes of poor flow and perfusion would be associated with a higher TRS. TRS and angiographic data were evaluated in 3,801 patients from the TIMI 4, 10A, 10B, 14, 20, 23, and 24 trials.Within each TRS stratum(TRS 0 to 2, 3 to 4, ≥5), 30-day mortality increased stepwise among patientswith impaired TFG at 60 minutes after fibrinolytic administration. In a multivariate model adjusting for the TRS strata, impaired TMPG(0/1) was independently associated with highermortality(odds ratio 2.28, p=0.018). In a multivariate model adjusting for the TFG and infarct location, the likelihood of impaired TMPG (0/1) was greater among intermediate-risk(TRS 3 to 4) and high-risk(TRS≥5) patients than among low-risk(TRS 0 to 2) patients(odds ratio 1.43, p=0.019 and 1.50, p=0.055, respectively). Thus, impaired epicardial flowand myocardial perfusion are independently associated with increased 30-day mortality among patients identified by TRS as high risk, although there is no synergism between either TFG or TMPG and TRS. High TRS at presentation is associated with abnormal myocardial perfusion, even after adjusting for possible confounders.展开更多
Background In patients with ST segment elevated myocardial infarction (STEMI) , early post thrombolysis routine angioplasty has been discouraged because of i ts association with high incidence of events. The GRACIA 1 ...Background In patients with ST segment elevated myocardial infarction (STEMI) , early post thrombolysis routine angioplasty has been discouraged because of i ts association with high incidence of events. The GRACIA 1 trial was designed t o reassess the benefits of an early postthrombolysis interventional approach in the era of stents and new antiplatelet agents. Methods 500 patients with thrombo lysed STEMI (with recombinant tissue plasminogen activator) were randomly assign ed to angiography and intervention if indicated within 24 h of thrombolysis, or to an ischaemia guided conservative approach. The primary endpoint was the comb ined rate of death, reinfarction, or revascularisation at 12 months. Analysis wa s by intention to treat. Findings Invasive treatment included stenting of the cu lprit artery in 80%(199 of 248) patients, bypass surgery in six (2%), non cul prit artery stenting in three, and no intervention in 40 (16%). Predischarge re vascularisation was needed in 51 of 252 patients in the conservative group. By c omparison with patients receiving conservative treatment, by 1 year, patients in the invasive group had lower frequency of primary endpoint (23 [9%] vs 51 [ 21 %], risk ratio 0.44 [95%CI 0.28-0.70], p=0.0008), and they tended to have red uced rate of death or reinfarction (7%vs 12%, 0.59 [0.33-1.05], p=0.07). In de x time in hospital was shorter in the invasive group, with no differences in maj or bleeding or vascular complications. At 30 days both groups had a similar inci dence of cardiac events. In hospital incidence of revascularisation induced by spontaneous recurrence of ischaemia was higher in patients in the conservative g roup than in those in the invasive group. Interpretation In patients with STEMI, early post thrombolysis catheterisation and appropriate intervention is safe a nd might be preferable to a conservative strategy since it reduces the need for unplanned in hospital revascularisation, and improves 1-year clinical outcome.展开更多
文摘In the setting of ST-segment elevation myocardial infarction (STEMI), the Thrombolysis In Myocardial Infarction (TIMI) risk score(TRS) and indexes of epicardial and myocardial perfusion are associated with mortality. The association between TRS at presentation and angiographic indexes of epicardial and myocardial perfusion after reperfusion therapy has not been investigated. We hypothesized that TRS, TIMI flow grade(TFG), and TIMI myocardial perfusion grade(TMPG) would provide independent prognostic information and that angiographic indexes of poor flow and perfusion would be associated with a higher TRS. TRS and angiographic data were evaluated in 3,801 patients from the TIMI 4, 10A, 10B, 14, 20, 23, and 24 trials.Within each TRS stratum(TRS 0 to 2, 3 to 4, ≥5), 30-day mortality increased stepwise among patientswith impaired TFG at 60 minutes after fibrinolytic administration. In a multivariate model adjusting for the TRS strata, impaired TMPG(0/1) was independently associated with highermortality(odds ratio 2.28, p=0.018). In a multivariate model adjusting for the TFG and infarct location, the likelihood of impaired TMPG (0/1) was greater among intermediate-risk(TRS 3 to 4) and high-risk(TRS≥5) patients than among low-risk(TRS 0 to 2) patients(odds ratio 1.43, p=0.019 and 1.50, p=0.055, respectively). Thus, impaired epicardial flowand myocardial perfusion are independently associated with increased 30-day mortality among patients identified by TRS as high risk, although there is no synergism between either TFG or TMPG and TRS. High TRS at presentation is associated with abnormal myocardial perfusion, even after adjusting for possible confounders.
文摘Background In patients with ST segment elevated myocardial infarction (STEMI) , early post thrombolysis routine angioplasty has been discouraged because of i ts association with high incidence of events. The GRACIA 1 trial was designed t o reassess the benefits of an early postthrombolysis interventional approach in the era of stents and new antiplatelet agents. Methods 500 patients with thrombo lysed STEMI (with recombinant tissue plasminogen activator) were randomly assign ed to angiography and intervention if indicated within 24 h of thrombolysis, or to an ischaemia guided conservative approach. The primary endpoint was the comb ined rate of death, reinfarction, or revascularisation at 12 months. Analysis wa s by intention to treat. Findings Invasive treatment included stenting of the cu lprit artery in 80%(199 of 248) patients, bypass surgery in six (2%), non cul prit artery stenting in three, and no intervention in 40 (16%). Predischarge re vascularisation was needed in 51 of 252 patients in the conservative group. By c omparison with patients receiving conservative treatment, by 1 year, patients in the invasive group had lower frequency of primary endpoint (23 [9%] vs 51 [ 21 %], risk ratio 0.44 [95%CI 0.28-0.70], p=0.0008), and they tended to have red uced rate of death or reinfarction (7%vs 12%, 0.59 [0.33-1.05], p=0.07). In de x time in hospital was shorter in the invasive group, with no differences in maj or bleeding or vascular complications. At 30 days both groups had a similar inci dence of cardiac events. In hospital incidence of revascularisation induced by spontaneous recurrence of ischaemia was higher in patients in the conservative g roup than in those in the invasive group. Interpretation In patients with STEMI, early post thrombolysis catheterisation and appropriate intervention is safe a nd might be preferable to a conservative strategy since it reduces the need for unplanned in hospital revascularisation, and improves 1-year clinical outcome.
