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.