Coronary Blood Flow Assessment After Successful Angioplasty for Acute Myocardial Infarction Predicts the Risk of Long-Term Cardiac Events

Background-We assessed coronary flow velocity pattern and coronary flow reserve (CFR) by contrast-enhanced transthoracic echocardiography (CE-TTE) as markers of major adverse cardiac events (MACE) related to cardiac allograft vasculopathy (CAV) after heart transplantation (HT). Methods and Results-Deceleration time of diastolic flow velocity (DDT) and CFR were measured in the left anterior descending coronary artery (LAD) by CE-TTE in 66 consecutive HT patients (follow-up 19Ϯ5 months). CFR was calculated as the ratio of hyperemic to basal diastolic flow velocity. Angiographies were analyzed by a qualitative grading system; CAV was defined as changes grade II or higher. MACE were cardiac death, stent implantation, and heart failure. Patients with MACE had higher CAV incidence (Pϭ0.004) and grade (Pϭ0.008), shorter DDT (Pϭ0.006), and lower CFR (Pϭ0.008).A receiver-operating characteristic-derived DDT cutpoint Յ840 ms (area under the curve 0.793; Pϭ0.01) was 75% specific and 86% sensitive for predicting MACE, with positive predictive value (PPV) and negative predictive value (NPV) of 33% and 97%, respectively (Pϭ0.002). A CFR cutpoint of Յ2.6 (area under the curve 0.746; Pϭ0.01) was 62% specific and 91% sensitive for predicting MACE (PPV ϭ32%, NPV ϭ97%) (Pϭ0.001). Patients with CFR Յ2.6 and patients with DDT Յ840 ms had a lower survival free from MACE (Pϭ0.006 and Pϭ0.009, respectively). By Cox regression, only a lower CFR predicted the risk of MACE (relative risk 3.1; 95% CI, 1.26 to 7.9; Pϭ0.01). Conclusions-In

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“…vascular damage, predicted the risk of long-term cardiac events after acute myocardial infarction 19 .…”

Section: I-53mentioning

confidence: 99%

Coronary Flow Velocity Pattern and Coronary Flow Reserve by Contrast-Enhanced Transthoracic Echocardiography Predict Long-Term Outcome in Heart Transplantation

Tona

Caforio²,

Montisci³

et al. 2006

Circulation

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“…However, successful restoration of epicardial flow does not necessarily translate into optimal reperfusion at the myocardial tissue level, and may result in microvascular See page 2239 obstruction (MO), also known as the "no-reflow" phenomenon (2). Experimental and clinical studies have demonstrated that MO is a common phenomenon and is associated with increased infarct size, reduced myocardial function, left ventricular (LV) remodeling, and worse clinical outcome (3)(4)(5)(6)(7)(8)(9)(10)(11). As a consequence, MO has important prognostic significance in patients after acute MI.…”

mentioning

confidence: 99%

Relation Between the Assessment of Microvascular Injury by Cardiovascular Magnetic Resonance and Coronary Doppler Flow Velocity Measurements in Patients With Acute Anterior Wall Myocardial Infarction

Hirsch

Nijveldt

Haeck

et al. 2008

Journal of the American College of Cardiology

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“…The small sample size may also explain why the diastolic deceleration time and the presence of systolic flow reversal in the infarctrelated artery did not predict mortality, whereas they have in other studies. 11,12 What remains unclear from this study is why some patients had a low CFVR in the nonculprit vessel and why this was predictive of adverse outcomes. Perhaps, the most likely explanation is that CFVR in the nonculprit vessel may be a reflection of the effects of a larger infarction on the wall motion in remote territories, the left ventricular end-diastolic pressure, and the neurohumoral response, all of which have been implicated in changes in coronary flow.…”

Section: Circ Cardiovasc Intervmentioning

confidence: 88%

Coronary Microvascular Dysfunction After ST-Segment–Elevation Myocardial Infarction

Yong

Fearon

2013

Circ: Cardiovascular Interventions

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V ariable degrees of coronary microvascular dysfunction occur at the time of ST-segment-elevation myocardial infarction (STEMI) correlating with infarct size and long-term prognosis. Angiographic methods for assessing microvascular dysfunction in the cardiac catheterization laboratory at the time of STEMI include thrombolysis in myocardial infarction flow grade, thrombolysis in myocardial infarction frame count, and thrombolysis in myocardial infarction myocardial perfusion grade.1 More recently, coronary wire-based methods measuring Doppler-derived parameters, such as the coronary flow velocity reserve (CFVR), or measuring thermodilutionderived parameters, such as the index of microcirculatory resistance, have been shown to be more powerful predictors of acute left ventricular dysfunction, myocardial viability, and subsequent adverse outcomes. 2,3 Article see p 207Although it is widely accepted that the degree of microvascular dysfunction occurring in the myocardium subtended by the infarct-related vessel correlates with infarct size and prognosis, there has been some debate on whether more global microvascular dysfunction, involving myocardial regions not supplied by the infarct-related vessel, is present at the time of STEMI. For example, Uren et al 4 performed positron emission tomography imaging in 13 patients with STEMI and found a decreased coronary flow reserve in the noninfarct-related vessel, which improved at 6-month follow-up. However, Ntalianis et al 5 measured fractional flow reserve in a nonculprit vessel at the time of STEMI in 75 patients and again 1 month later and found no significant difference in fractional flow reserve or in index of microcirculatory resistance, which was measured in a subgroup, suggesting that the microvascular dysfunction resulting from STEMI is limited to the territory supplied by the infarct-related artery.In this issue of Circulation: Cardiovascular Interventions, van de Hoef et al 6 report long-term follow-up in 100 patients presenting with STEMI, in whom they measured Doppler wire-derived CFVR, diastolic deceleration time, and systolic flow reversal in both the infarct-related artery and a nonculprit reference vessel. They found that the mean CFVR value in the infarct-related vessel was 1.6±0.4 and in the nonculprit vessel, it was 2.4±0.5. A normal CFVR value is generally thought to be >2.0. Interestingly, they found that CFVR in the nonculprit reference artery was an independent predictor of long-term cardiac mortality (hazard ratio, 4.1; 95% confidence interval, 1.2-14.2). On the basis of receiver operator characteristic curve analysis, 2.1 was the best cutoff value, with 35% of patients having a CFVR value below this cut point in the nonculprit vessel. The diastolic deceleration time, presence or absence of systolic flow reversal, and the CFVR measured in the infarct-related artery surprisingly were not predictive of long-term cardiac mortality.The implications of the findings are that microvascular dysfunction in the setting of STEMI can be global, and may not on...

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Coronary Blood Flow Assessment After Successful Angioplasty for Acute Myocardial Infarction Predicts the Risk of Long-Term Cardiac Events

Cited by 45 publications

References 33 publications

Coronary Flow Velocity Pattern and Coronary Flow Reserve by Contrast-Enhanced Transthoracic Echocardiography Predict Long-Term Outcome in Heart Transplantation

Coronary Flow Velocity Pattern and Coronary Flow Reserve by Contrast-Enhanced Transthoracic Echocardiography Predict Long-Term Outcome in Heart Transplantation

Relation Between the Assessment of Microvascular Injury by Cardiovascular Magnetic Resonance and Coronary Doppler Flow Velocity Measurements in Patients With Acute Anterior Wall Myocardial Infarction

Coronary Microvascular Dysfunction After ST-Segment–Elevation Myocardial Infarction

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