to higher event rates and a more limited life span thanyounger patients, the primary indication for PCI in theelderly is as a treatment for anginal symptoms. Al-though PCI offers better outcome than pharmacologicthrombolysis in the setting of acute myocardial infarc-tion,19,20 the role of primary PCI for reperfusion isuncertain in octogenarians. As Gravina Taddei et al1

previously pointed out: “In no other age group isquality of life so relatively valued compared with sur-vival . . . High quality medical care of the octogen-arian . . . must have as a main goal the preservation ofan autonomous life, with dignity and self respect.”

PCI in octogenarians is associated with a overallmortality of 3.5%, 2.2% in elective cases and14.1% after acute myocardial infarction. The mor-tality rate is increased with decreased left ventric-ular function, diabetes, a first PCI, or an increasedneed for an emergency procedure.

1. Gravina Taddei CF, Weintraub WS, Shaw L, Kosinski AS. Coronary angio-plasty and other transcatheter revascularization procedures. In: Wenger NK, ed.Cardiovascular Disease in the Octogenarian and Beyond. London: Martin Dunitz,1999:185–204.2. Kowalchuk GJ, Siu SC, Lewis SM. Coronary artery disease in the octogenar-ian: angiographic spectrum and suitability for revascularization. Am J Cardiol1990:1319–1323.3. Kern MJ, Deligonul U, Galan K, Zelman R, Gabliani G, Bell ST, Bodet J,Naunheim K, Vandormael M. Percutaneous transluminal coronary angioplasty inoctogenarians. Am J Cardiol 1988;61:457–458.4. Jeroudi MO, Kleiman NS, Minor ST, Hess KR, Lewis JM, Winters WL Jr,Raizner AE. Percutaneous transluminal coronary angioplasty in octogenarians.Ann Int Med 1990;113:423–428.5. Forman DE, Berman AD, McCabe CH, Baim DS, Wei JY. PTCA in theelderly: the “young-old” versus the “old-old”. J Am Geriatr Soc 1992;40:19–22.6. Rich JJ, Crispino CM, Saporito JJ, Domat I, Cooper WM. Percutaneoustransluminal coronary angioplasty in patients 80 years of age and older. Am JCardiol 1990;65:675–676.7. Rizo-Patron C, Hamad N, Paulus R, Garcia J, Beard E. Percutaneous translu-

minal coronary angioplasty in octogenarians with unstable coronary syndromes.Am J Cardiol 1990;66:857–858.8. Myler RK, Webb JG, Nguyen KPV, Shaw RE, Anwar A, Schechtmann NS,Bashour TT, Stertzer SH, Zapolanski A. Coronary angioplasty in octogenarians:comparisons to coronary bypass surgery. Cathet Cardiovasc Diagn 1991;23:3–9.9. Jackman JD Jr, Navetta FI, Smith JE, Tcheng JE, Davidson CJ, Phillips HR,Califf RM, Nelson CL, Gardner LH, Stack RS. Percutaneous transluminal cor-onary angioplasty in octogenarians as an effective therapy for angina pectoris.Am J Cardiol 1991;68:116–119.10. Little T, Milner MR, Lee K, Constantine J, Pichard AD, Lindsay J Jr. Lateoutcome and quality of life following percutaneous transluminal coronary angio-plasty in octogenarians. Cathet Cardiovasc Diagn 1993;29:261–266.11. Laster SB, Rutherford BD, Giorgi LV, Shimshak TM, McConahay DR,Johnson WL Jr, Huber KC, Ligon RW, Hartzler GO. Results of direct percuta-neous transluminal coronary angioplasty in octogenarians. Am J Cardiol 1996;77:10–13.12. Kaul TK, Fields BL, Wyatt DA, Jones CR, Kahn DR. Angioplasty versuscoronary artery bypass in octogenarians. Ann Thorac Surg 1994;58:1419–1426.13. Rozenman Y, Mosseri M, Lotan C, Hasin Y, Gotsman MS. Percutaneoustransluminal coronary angioplasty in octogenarians. Am J Geriatr Cardiol 1995;4:38–41.14. Hussain KMA, Sankari AH, Jain A, Bargout R, Chandra H, Denes P. Resultsof stent supported percutaneous transluminal coronary angioplasty in octogenar-ians with coronary artery disease. Am J Geriatric Cardiol 2000;9:219–223.15. Gravina Taddei CF, Weintraub WS, Douglas JS, Ghazzal Z, Mahoney EM,Thompson T, King SB. Influence of age on outcome after percutaneous translu-minal coronary angioplasty. Am J Cardiol 1999;84:245–251.16. Batchelor WB, Anstrom KJ, Muhlbaier LH, Grosswald R, Weintraub WS,O’Neill WW, Peterson ED. Contemporary outcome trends in the elderly under-going percutaneous coronary interventions: results in 7,472 octogenarians. J AmColl Cardiol 2000;36:723–730.17. Kahler J, Lutke M, Weckmuller J, Koster R, Meinertz T, Hamm CW.Coronary angioplasty in octogenarians. Quality of life and costs. Euro Heart J1999;20:1791–1798.18. Spertus JA, Winder JA, Dewhurst TA, Deyo RA, Prodzinski J, McDonell M,Fihn SD. Development and evaluation of the Seattle Angina Questionnaire: a newfunctional status measure for coronary artery disease. J Am Coll Cardiol 1995;25:333–341.19. Grines CL, Browne KF, Marco J, Rothbaum D, Stone GW, O’Keefe J,Overlie P, Donohue B, Chelliah N, Timmis GC, et al. A comparison of immediateangioplasty with thrombolytic therapy for acute myocardial infarction. N EnglJ Med 1993;328:673–679.20. Stone GW, Brodie BR, Griffin JJ, Costantini C, Morice MC, St Goar FG,Overlie PA, Popma JJ, McDonnell J, Jones D, O’Neill WW, Grines CL. Clinicaland angiographic follow-up after primary stenting in acute myocardial infarction:the Primary Angioplasty in Myocardial Infarction (PAMI) stent pilot trial. Cir-culation 1999;99:1548–1554.

Relation of Stenting to Decreased Coronary Blood FlowDuring Primary Angioplasty in Acute

Myocardial Infarction

Jorge Escobar, MD, Eduardo Guarda, MD, Eugenio Marchant, MD,Alejandro Fajuri, MD, Alejandro Martınez, MD, and Augusto Pichard, MD

During the past few years, the use of coronarystents during primary percutaneous coronary in-

terventions (PCI) has reduced the acute and subacutecomplications of this procedure and the incidence ofmajor cardiac events such as death, reinfarction, rein-terventions, and restenosis during the first 6 monthsafter PCI.1,2 We have observed in our laboratory thatcoronary blood flow (CBF) decreases in some patientsafter stenting during primary PCI for acute myocardial

infarction (AMI). Herein, we report CBF assessed bythe Thrombolysis In Myocardial Infarction [TIMI]frame count after stent implantation during primaryPCI.

• • •Between January 1996 and August 1998, 101 con-

secutive patients with AMI were managed with pri-mary PCI followed by stenting. This study included75 of these patients (57 men [76%]), mean age 61 �13 years). Twenty-six were excluded because of tech-nically inadequate cine films for measurements ofTIMI frame count (20 patients) or because the infarct-related vessel was a graft (6 patients).

PCI was performed immediately after arrival to thecardiac catheterization laboratory using standard tech-

From the Department of Cardiovascular Diseases, Catholic Universityof Chile, Santiago, Chile; and Washington Medical Center, Wash-ington, DC. Dr. Guarda’s address is: Laboratorio de Hemodinamia,Marcoleta 367, Santiago, Chile. E-mail: eguarda@med.puc.cl.Manuscript received April 30, 2001; revised manuscript received andaccepted August 23, 2001.

1410 ©2001 by Excerpta Medica, Inc. All rights reserved. 0002-9149/01/$–see front matterThe American Journal of Cardiology Vol. 88 December 15, 2001 PII S0002-9149(01)02121-X

niques.3 Angiographic conditions such as angle andskew of the gantry, angiographic views, and contrastagent were reproduced to minimize variability in im-aging CBF after ballooning or stenting. The reason forstenting was elective in 60 patients (80%) and elasticrecoil in 15 patients (20%). Final mean pressure forthe balloon was 10.5 � 2.0 atm, and for stenting, 13 �2.5 atm. All angiograms were recorded at 25 frames.

To quantify CBF, we followed the protocol de-scribed by Gibson et al.4 Briefly, TIMI frame count isthe number of cine frames required for contrast mediato first reach standarized distal coronary landmarks inan infarct-related coronary artery. TIMI frame countbegan in a frame in which the contrast media thor-

oughly entered into the artery and ended when themedia completely opacified the distal reference. Thefollowing distal landmark branches were used foranalysis: the distal bifurcation of the left anteriordescending artery in the circumflex system; the distalbifurcation of the segment with the longest total dis-tance, which includes the infarct-related lesion; and inthe right coronary artery, the first branch of the pos-terolateral artery. The measurement of the TIMI framecount was accomplished in a Tagarno 35AX system(Tagarno of America, Inc., Dover, Delaware)equipped with a cine frame counter. We performed 3measurements of the CBF: at the initial angiogram,after PCI with balloon, and after stent implantation.Because the left anterior descending artery is longerthan the remaining arteries, it was normalized by afactor of 1.7.4 Arbitrarily, we assigned a TIMI framecount of 100 in cases of complete occlusion of theinfarct-related artery. This allowed us to compare theeffects of the interventions on CBF.

Measurements were obtained using the methoddescribed by Casar et al.5 The films were scanned andthe digital images were measured using software ob-tained from the National Institutes of Health usingcatheters of known diameter for comparison. We mea-sured the luminal diameter of the reference vessel, theminimal luminal diameter, and the percentages ofstenosis in the infarct-related artery in the initial an-giogram after balloon angioplasty and after stent im-plantation.

Data were collected every 3 months and up to 24months after PCI. We registered thefollowing major cardiac events:death, new AMI and new revascular-ization procedures, and PCI or coro-nary artery bypass surgery.

• • •From the beginning of the AMI to

the moment of starting PCI there wasa delay of 3.6 � 2.3 hours. Accord-ing to electrocardiographic criteria,AMI was anterior in 36 patients(48%), inferior in 33 (44%), and lat-eral wall in 6 (8%). These and otherclinical characteristics are listed inTable 1. In the initial angiogram, wefound that the infarct-related arteryin AMI involved the left anterior de-

scending artery in 35 patients (47%), the right coro-nary artery in 31 (41%), and the circumflex in 9(12%). The infarct-related artery was occluded on theinitial angiogram in 55 patients (73%). Abciximabwas given to 12 of 75 patients (15%). The results ofquantitative angiography are shown in Table 2. Asexpected, there was a significant improvement in min-imal luminal diameter after stent implantation. Thepercentage of residual stenosis after stenting was 10.7� 17%.

CBF improved after balloon angioplasty, from aTIMI frame count of 90 � 25 to 29 � 26 frames (p�0.001); it remained unchanged after stenting (25 �22 frames). However, we found that the effect of

TABLE 1 Clinical Profile

Variable No (%)

Systemic hypertension 34 (45)Diabetes mellitus 9 (12)Smoking 32 (43)Previous myocardial

infarction7 (9)

Previous coronarybypass

2 (3)

AMIAnterior 36 (48)Inferior 33 (44)Lateral 6 (8)

Killip class1 37 (49)2 20 (27)3 8 (11)4 10 (13)

Intraaortic balloon pump 14 (19)Pacemaker during PCI 26 (35)Use of abciximab 12 (15)

TABLE 2 Quantitative Angiography

Reference vessel (mm) 3.94 � 1.0

Initial minimal luminal diameter (mm) 0.25 � 0.42% stenosis 94 � 10Minimal luminal diameter after balloon

angioplasty (mm)2.11 � 0.75*

% stenosis 46 � 22*Minimal luminal diameter after stent

(mm)3.57 � 0.94

% stenosis 11 � 17

*p �0.0005 between after balloon versus after stenting.

TABLE 3 Quantitative Angiography and Changes in TIMI Frame Count

CBF

Faster(n � 27)

No Change(n � 25)

Slower(n � 23)

Reference vessel (mm) 3.78 � 1.07 4.04 � 0.73 4.01 � 1.15Initial minimal luminal diameter (mm) 0.42 � 0.54 0.09 � 0.28 0.22 � 0.35% stenosis 90.3 � 13.3 98.4 � 4.54 94.5 � 9.31Minimal luminal diameter after balloon

angioplasty (mm)2.14 � 0.71 2.13 � 0.90 2.08 � 0.68

% stenosis 41.1 � 22.4 49.9 � 22.5 46.2 � 18.3Minimal luminal diameter after stent (mm) 3.26 � 1.12 3.73 � 0.62 3.71 � 1.00% stenosis 13 � 14 12 � 23 6.8 � 9.9

BRIEF REPORTS 1411

stenting on CBF was heterogenous in different pa-tients: CBF after stenting was considered faster thanCBF after balloon angioplasty if the TIMI frame countwas reduced �3 frames. There was no change in CBFif the TIMI frame count after stenting did not vary �2 frames after balloon angioplasty, and it was judgedto be slower after stenting than after balloon angio-plasty if the TIMI frame count increased �3 frames.According to these criteria, stent implantation pro-duced improvement in CBF in 27 patients, no changein 25, and slowed CBF in the remaining 23 patients.Stent implantation improved CBF only in patientswith slow flow (TIMI frame count 44 � 32 frames),which improved to 21 � 19 frames after stent implan-tation (p �0.00004). These changes in CBF could notbe attributed to differences in vessel diameter or thefinal minimal luminal diameter after PCI. Table 3shows the quantitative angiographic results in thesame 3 groups of patients. It can be appreciated thatthere were no significant differences in the diameter ofthe reference vessels, or in the minimal luminal diam-eter after performing balloon angioplasty or stentingamong the 3 groups.

To analyze the impact of balloon or stent deploy-ment on the incidence of major clinical events duringfollow-up, we arbitrarily divided patients betweenthose with TIMI frame count �30 and �30 framesafter balloon angioplasty. Four of 55 patients (7.2%)with a TIMI frame count �30 frames after balloonangioplasty had �1 major clinical event, and 8 of 20(40%) with �30 frames (p �0.0006) had �1 event.We observed no differences in events among patientswhose TIMI frame counts were faster, equal, orslower after stenting.

• • •In our study, implantation of a coronary stent dur-

ing primary PCI produced a nonsignificant improve-ment in coronary flow compared with the TIMI framecount after balloon angioplasty (29 � 26 vs 25 � 22frames). Moreover, we found that stenting improvedCBF in only 36% of patients. In 33% of patients, CBFdid not vary, and in 31%, CBF worsened significantlyafter stenting. We could not find clinical or angio-graphic predictors in patients with decreased flowafter stenting. Quantitative angiography demonstratedthat these parameters were similar among patients;therefore, the reasons for the deterioration of CBF insome patients must be sought in other causes, inde-pendent of the lumen of epicardial arteries.6–10

The information in this area is scarce. Edep et al11

also compared the effects of PCI and stenting on theflow of the infarct-related artery. They performed pri-mary angioplasty in 19 AMI patients with the balloon

alone, whereas 20 patients were treated with balloonplus stents. They obtained better TIMI frame counts inpatients who received stents than in the balloon-alonegroup (16.1 vs 30.7 frames, p �0.002). We believetheir results were different from ours because in theirstudy, stenting clearly achieved a greater postproce-dure minimal luminal diameter and a smaller residualstenosis than balloon angioplasty alone, which mayexplain why this procedure alone had a worse TIMIframe count than patients who received stents.

In this study, we found that in patients withAMI, CBF significantly improved after PCI withthe balloon; however, the addition of a stent didnot change flow significantly. In fact, in one third ofthe patients, stent implantation was associated witha significant reduction of CBF. Flow after stentingimproved only in patients with low CBF after bal-loon angioplasty. Additional studies are necessaryto identify patients in whom stent implantationmay result in decreased CBF.

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1412 THE AMERICAN JOURNAL OF CARDIOLOGY� VOL. 88 DECEMBER 15, 2001