Comparative prognostic utility of indexes of microvascular function alone or in combination in patients with an acute ST-segment elevation myocardial infarction

Carrick, D. et al. (2016) Comparative prognostic utility of indexes of microvascular function alone or in combination in patients with an acute ST-segment elevation myocardial infarction. Circulation, 134(23), pp. 1833-1847. (doi:10.1161/CIRCULATIONAHA.116.022603) (PMID:27803036) (PMCID:PMC5131697)

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Abstract

Background—Primary percutaneous coronary intervention (PCI) is frequently successful at restoring coronary artery blood flow in patients with acute ST-segment elevation myocardial infarction, however, failed myocardial reperfusion commonly passes undetected in up to half of these patients. The index of microvascular resistance (IMR) is a novel invasive measure of coronary microvascular function. We aimed to investigate the pathological and prognostic significance of an index of microvascular resistance (IMR>40), alone or in combination with a coronary flow reserve (CFR≤2.0), in the culprit artery after emergency PCI for acute STEMI. Methods—Patients with acute STEMI were prospectively enrolled during emergency PCI, and categorized according to IMR (≤40 or >40) and CFR (≤2.0 or >2.0). Cardiac MRI was acquired 2 days and 6 months post-MI. All-cause death or first heart failure hospitalization was a pre-specified outcome (median follow-up duration 845 days). Results—IMR and CFR were measured in the culprit artery at the end of PCI in 283 STEMI patients (mean age 60 (12) years, 73% male). The median [interquartile range] IMR and CFR were 25 [15-48] and 1.6 [1.1-2.1], respectively. An IMR>40 was a multivariable associate of myocardial hemorrhage (odds ratio (OR) (95% confidence interval (CI)) 2.10 (1.03, 4.27); p=0.042. An IMR>40 was closely associated with microvascular obstruction. Symptom to reperfusion time, TIMI blush grade, and no (≤30%) ST segment resolution, were not associated with these pathologies. An IMR>40 was a multivariable associate of the changes in LV ejection fraction (coefficient (95% CI) (-2.12 (-4.02, -0.23); p=0.028) and LV end-diastolic volume (7.85 (0.41, 15.29); p=0.039) at 6 months, independent of infarct size. An IMR>40 (odds ratio 4.36 (95% CI 2.10, 9.06); p<0.001) was a multivariable associate of all-cause death or heart failure. Compared with an IMR>40, the combination of IMR>40 with CFR≤2.0 did not have incremental prognostic value. Conclusions—An IMR>40 is a multivariable associate of LV and clinical outcomes post-STEMI, independent of the size of infarction. Compared with standard clinical measures of the efficacy of myocardial reperfusion, including the ischemic time, ST-segment elevation, the angiographic blush grade and CFR, IMR has superior clinical value for risk stratification and may be considered as a reference test for failed myocardial reperfusion.

Item Type:Articles
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:Berry, Professor Colin and Carrick, Dr David and Petrie, Professor Mark and Eteiba, Dr Hany and Oldroyd, Dr Keith and Haig, Dr Caroline and Mordi, Dr Ify and Ford, Professor Ian and Radjenovic, Dr Aleksandra and Ahmed, Mr Nadeem and Hood, Dr Stuart
Authors: Carrick, D., Haig, C., Ahmed, N., Carberry, J., Teng Yue May, V., McEntegart, M., Petrie, M. C., Eteiba, H., Lindsay, M., Hood, S., Watkins, S., Davies, A., Abouzaid, A. M., Mordi, I., Ford, I., Radjenovic, A., Oldroyd, K. G., and Berry, C.
College/School:College of Medical Veterinary and Life Sciences > Institute of Cardiovascular and Medical Sciences
College of Medical Veterinary and Life Sciences > Institute of Health and Wellbeing > Robertson Centre
College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing
Journal Name:Circulation
Publisher:American Heart Association
ISSN:0009-7322
ISSN (Online):1524-4539
Published Online:01 November 2016
Copyright Holders:Copyright © 2016 The Authors
First Published:First published in Circulation 134(23):1833-1847
Publisher Policy:Reproduced under a Creative Commons License
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