Is PCI necessary for AMI related Is PCI necessary for AMI related artery with TIMI 3 flow ? artery with TIMI 3 flow ?
Donghoon Choi
Yonsei Cardiovascular CenterYonsei University College of Medicine
M/63
Chest pain of 1 hour
Coronary Angiography Coronary Angiography
What do you think
the fate of m-LAD
after primary PCI will be ?
Primary PTCA VS Thrombolysis Primary PTCA VS Thrombolysis
Weaver WD et al. JAMA 1997;278:2093
0
20
40
60
80
100
TIMI 3 Flow Death Death or MI CVA ICH
PTCA Thrombolysis**
** **** **
* p<0.001* p<0.001(%)(%)
TIMI Flow Grades at Initial AngiogrTIMI Flow Grades at Initial Angiographyaphy
72.8%
14.4%12.8%
76.1%
12.9%11.0%
70.4%
10.8%
18.8%
65.9%
12.7%
21.4%
71.2%
12.7%16.1%
0%
20%
40%
60%
80%
100%
PAMI-1 PAMI-2 PAMI StentPilot
PAMI StentTrial
Pooled
TIMI 0/1 TIMI 2 TIMI 3
Stone GW et al. Circulation 2001;104:636
% patients
n=2507
Survival after Primary PTCA in AMI Survival after Primary PTCA in AMI by Initial TIMI Flowby Initial TIMI Flow
90%
92%
94%
96%
98%
100%
0 1 2 3 4 5 6
TIMI 3
TIMI 2
TIMI 0/1
Stone GW et al. Circulation 2001;104:636
Final TIMI Flow after Primary PCI Final TIMI Flow after Primary PCI and 30-day Mortality in AMIand 30-day Mortality in AMI
21.4%
14.3%
19.9%
1.6%
0%
10%
20%
30%
TIMI 0 TIMI 1 TIMI 2 TIMI 3
GUSTO IIb NEJM 1997;336:1621
Final TIMI 3 Flow !!!Final TIMI 3 Flow !!!
Primary PCIPrimary PCI Pre Post ballon angioplasty
M/63
Primary PCIPrimary PCI After IC Verapmil Post stenting (GFX 3.0 x 24)
M/63
Pathophysiology of AMIPathophysiology of AMI
Ruptured fibrous cap with thrombus
Embolized Platelet Aggregate in Embolized Platelet Aggregate in a Small Myocardial Arteriolea Small Myocardial Arteriole
Likelihood of Distal EmbolizationLikelihood of Distal Embolization
Spontaneous reperfusion Spontaneous reperfusion (endogenous thrombolysis)(endogenous thrombolysis)
Thrombolytic therapyThrombolytic therapy
PTCAPTCA
StentingStentingmore more
less less
STENT- PAMISTENT- PAMI
92.9%
89.4%
85%
90%
95%
PTCA Stent
2.7%
4.2%
0%
1%
2%
3%
4%
5%
PTCA Stent
6 month mortalityFinal TIMI 3 flow
Grines CL et al. NEJM 1999;341:1949
p=0.10 p=0.27
Cura et al. JACC 2001;88:124
Final TIMI Flow in Relation to Final TIMI Flow in Relation to Initial TIMI FlowInitial TIMI Flow
8%
92%
15%
85%
21%
79%
Pre TIMI 0,1(n = 649)
Pre TIMI 2(n = 166)
Pre TIMI 3(n = 76)
Final TIMI Flow : TIMI 3 TIMI 0, 1, 2
Impact of Stenting on Coronary Blood Flow Impact of Stenting on Coronary Blood Flow after Balloon angioplasty in Primary PCIafter Balloon angioplasty in Primary PCI
36%
33%31%
20%
25%
30%
35%
40%
Improved not changed worsened
Escobar et al. AJC 2001;88:1410
based on frame count
patients
Effects of Adjuvant Balloon Effects of Adjuvant Balloon on CT-Frame Count on CT-Frame Count
0
10
20
30
40
50
Increased Decreased No change
• Increased CTFC
: 20 pts(43.5%)
• Decreased CTFC
: 15 pts(32.6%)
• No change in CTFC
: 11pts(23.9%)Change in CTFC
% o
f to
tal p
ts 43.5%
32.6%
23.9%
Koo BG et al. Korean Circulation in Press
TIMI 3 Flow !!!TIMI 3 Flow !!!
Survival by Initial and Final Survival by Initial and Final Procedural TIMI flowProcedural TIMI flow
0 30 60 90 120 150 180
75%
80%
85%
90%
95%
100%
TIMI Flow N (%) 6 month pre post patients mortality
3 3 368(15.8%) 0%
0~2 3 1,786(76.8%) 3.6% 0~2 0~2 166 (7.1%) 8.6%
3 0~2 7 (0.3%) 20.0%
Stone GW et al. Circulation 2001;104:636
CADILLACCADILLAC
4.5%
2.5%
3.0%
4.2%
1.8%
2.7%
1.6%
2.20%
0%
1%
2%
3%
4%
5%
PTCA PTCA +Abciximab
Stenting Stenting +Abciximab
6-month mortality reinfarction
P = NS
Stone GW et al. NEJM 2002;346:957
ConclusionConclusion
Primary PCI can harm coronary blood f
low in AMI.
Therefore, PCI is neccesary only in AM
I with impaired initial coronary perfusio
n.