One-year results from the Assessing MICRO-vascular resistances via IMR to predict outcome in ST-elevation myocardial infarction patients with multivessel disease undergoing primary PCI (AMICRO) trial

Abstract

BackgroundIn ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary angioplasty (PPCI) the index of microcirculatory resistance (IMR) correlates to the extent of myocardial damage and left ventricular (LV) function recovery. Data on the IMR time-course and impact on clinical outcome in STEMI patients with multi-vessel disease (MVD) are scarce.AimsWe designed a prospective, multicenter clinical trial to assess the infarct-related artery (IRA)-IMR in STEMI patients with MVD undergoing PPCI and to explore its potential in relationship with outcome and LV remodeling.MethodsThe study enrolled 242 STEMI patients with MVD. Both fractional flow reserve (FFR) and IMR of the IRA were assessed after successful PPCI. Then, FFR/IMR measurements were repeated in the IRA at a staged angiography, and FFR-guided angioplasty was performed in non-IRA lesions. The primary endpoint was the composite of cardiovascular death, re-infarction, re-hospitalization for heart failure, resuscitation or appropriate ICD shock at 1-year follow-up.ResultsA significant improvement of IRA-IMR values (from 47.9 to 34.2, p < 0.0001) was observed early after PPCI. Staged FFR-guided angioplasty was performed in 102 non-IRA lesions. We failed to find a correlation between IRA-IMR, clinical events and LV remodeling. Notwithstanding, in patients with anterior STEMI an inverse correlation between initial IMR values and LV function at follow-up was observed.ConclusionAfter successful PPCI, a significant proportion of patients with STEMI and MVD had coronary microvascular dysfunction as assessed by IMR that recovered early after reperfusion. Higher IMR values predicted lack of improvement of LV function only in anterior STEMI.Clinical trial registrationhttps://clinicaltrials.gov/, identifier [NCT 02325973].

Impact of Coronary Microvascular Dysfunction on Functional Left Ventricular Remodeling and Diastolic Dysfunction

“…Persistent CMD in these studies was also associated with LVEF recovery. 26 , 39 Hence, persistent CMD after STEMI is likely the cause of myocardial necrosis and adverse LV remodeling in our study.…”

“…However, the trial did not show similar outcomes for patients with nonanterior STEMI, potentially attributable to an underpowered sample size. 26 …”

Microvascular function, plaque characteristics and prognostic effect in STEMI with early spontaneous reperfusion: Insights from intravascular ultrasound and coronary physiology

“…Fractional ow reserve (FFR) was introduced to assess the physiological function of coronary artery lesion [9], which brought the conception of functional completely revascularization (FCR) comparing to the traditional idea of lumen geometric revascularization and since then cardiologists paid more attention to regaining the whole function of vascular instead of reconstructing the lumen simply [9,10]. Achieving FCR has been already proved to be associated with markedly lower rates of MACE [11,12].…”

Clinical variables associated with no-reflow after percutaneous coronary intervention in ST-segment elevation myocardial infarction: Secondary analysis of the PERSTEMI I and II study

“…En el futuro, las investigaciones apuntan a evaluar mecanismos de protección endógena a la isquemia, como el pre y posacondicionamiento, o terapias que actúen sobre la contracción de los pericitos (células contráctiles ubicadas a nivel capilar) con el fin de evitar la progresión del daño en la microvasculatura 14 , 17 , 34 . Otras propuestas se han enfocado en aspectos técnicos relacionados con el procedimiento intervencionista, como la utilización de stents diseñados con micromallas para atrapar trombos, la reperfusión lenta, insuflación prolongada y la detección temprana en la sala de procedimientos con la medición de la resistencia microcirculatoria (IMR) para intensificar y optimizar el tratamiento de los pacientes 35 , 36 . Una vez más enfatizando que todo esto es aún experimental y que vale la pena siempre actuar desde la prevención, como decía Niccoli et al: «Una vez más, es mejor prevenir que tratar» 17 .…”