capillary lumen

11
Time is Muscle: Delays in Symptom to Door Time are Time is Muscle: Delays in Symptom to Door Time are Associated with Poorer Flow in the Muscle Independent Associated with Poorer Flow in the Muscle Independent of Flow in Artery of Flow in Artery 16% rise in risk of a closed muscle for every hour of delay in STEMI (p=0.0005) CM Gibson, JACC 2004 Capillary Lumen Time Dependent Time Dependent Wavefront of Necrosis Wavefront of Necrosis Swollen / Closed Anterior Swollen / Closed Anterior Myocardium Myocardium Blistering of Capillaries Blistering of Capillaries & Endothelium & Endothelium

Upload: arama

Post on 06-Jan-2016

64 views

Category:

Documents


2 download

DESCRIPTION

Capillary Lumen. Time is Muscle: Delays in Symptom to Door Time are Associated with Poorer Flow in the Muscle Independent of Flow in Artery. 16% rise in risk of a closed muscle for every hour of delay in STEMI (p=0.0005) CM Gibson, JACC 2004. Swollen / Closed Anterior Myocardium. - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: Capillary Lumen

Time is Muscle: Delays in Symptom to Door Time are Associated Time is Muscle: Delays in Symptom to Door Time are Associated with Poorer Flow in the Muscle Independent of Flow in Arterywith Poorer Flow in the Muscle Independent of Flow in Artery

Time is Muscle: Delays in Symptom to Door Time are Associated Time is Muscle: Delays in Symptom to Door Time are Associated with Poorer Flow in the Muscle Independent of Flow in Arterywith Poorer Flow in the Muscle Independent of Flow in Artery

16% rise in risk of a closed muscle for every hour of delay in STEMI (p=0.0005) CM Gibson, JACC 200416% rise in risk of a closed muscle for every hour of delay in STEMI (p=0.0005) CM Gibson, JACC 2004

Capillary Lumen

Time DependentTime Dependent

Wavefront of NecrosisWavefront of Necrosis

Swollen / Closed Anterior Swollen / Closed Anterior

MyocardiumMyocardiumBlistering of CapillariesBlistering of Capillaries

& Endothelium& Endothelium

Page 2: Capillary Lumen

55.1

46.5

0

20

40

60

Delay in Delay in Time from Symptom Onset to Treatment and TIMI Time from Symptom Onset to Treatment and TIMI Myocardial Perfusion Grade at 60 minutesMyocardial Perfusion Grade at 60 minutes

3.02

2.72

0

1

2

3

4

n=625n=625 Tim

e fr

om

sx

on

set

to t

reat

men

t (h

rs)

Tim

e fr

om

sx

on

set

to t

reat

men

t (h

rs)

TMPG 2/3TMPG 2/3 TMPG 0/1TMPG 0/1

% T

MP

G 2

/3%

TM

PG

2/3

n=549n=549

25th/75th25th/75th

PercentilePercentile

2 / 3.752 / 3.75

25th/75th25th/75th

PercentilePercentile

2.2 / 4.052.2 / 4.05

n=258n=258

p = 0.014p = 0.014

Time to Time to treatment treatment >4 hours>4 hours

Time to Time to treatment treatment 4 hours4 hours

n=916n=916

For impaired tissue perfusion,For impaired tissue perfusion,MV OR 1.16 per hour of delayMV OR 1.16 per hour of delay

p = 0.003p = 0.003

Gibson CM, J Am Coll Cardiol 2004Gibson CM, J Am Coll Cardiol 2004

Page 3: Capillary Lumen

79.5

71.3

0

20

40

60

80

100

Delay in Time from Symptom Onset to Treatment and TIMI Flow Grade at 60 minutes

3.25

2.75

0

1

2

3

4

n=1,870

p < 0.001

Tim

e fr

om

sx

on

set

to t

reat

men

t (h

rs)

TFG 2/3 TFG 0/1

% T

FG

2/3

n=545

25th/75th

Percentile

2 / 3.9

25th/75th

Percentile

2.3 / 4.6

n=614

p < 0.001

Time to treatment >4 hours

Time to treatment 4 hours

n=1,801

Gibson CM, J Am Coll Cardiol 2004Gibson CM, J Am Coll Cardiol 2004

Page 4: Capillary Lumen

Delay in Time from Symptom Onset to Treatment and Corrected TIMI Frame Count at 60 minutes

42.9

38.2

0

10

20

30

40

50

n=583 Co

rrec

ted

TIM

I F

ram

e C

ou

nt

(fra

mes

)

n=1,679

p = 0.001

Time to treatment >4 hours

Time to treatment 4 hours

25th/75th

Percentile

27.6 / 100

25th/75th

Percentile

25 / 100

Gibson CM, J Am Coll Cardiol 2004Gibson CM, J Am Coll Cardiol 2004

Page 5: Capillary Lumen

Delay in Time from Symptom Onset to Treatment and Myocardial Blush on Digital Subtraction Angiography

6.6

8.0

0

2

4

6

8

10

n=213 Blu

sh B

rig

htn

ess

on

DS

A (

gra

y sc

ale)

n=745

p = 0.02

Time to treatment >4 hours

Time to treatment 4 hours

25th/75th

Percentile

2.9 / 11

25th/75th

Percentile

3.5 / 12.6

Gibson CM, J Am Coll Cardiol 2004Gibson CM, J Am Coll Cardiol 2004

Page 6: Capillary Lumen

12.4

16.1

0

5

10

15

20

Delay in Delay in Time from Symptom Onset to Treatment and Time from Symptom Onset to Treatment and Ejection Fraction and CollateralsEjection Fraction and Collaterals

58.855.3

0

20

40

60

n=495n=495

p < 0.0001p < 0.0001

Eje

ctio

n f

ract

ion

(%

)E

ject

ion

fra

ctio

n (

%)

Co

llat

eral

s (%

)C

oll

ater

als

(%)

n=1,360n=1,360 n=930n=930

p = 0.004p = 0.004

Time to Time to treatment treatment >4 hours>4 hours

Time to Time to treatment treatment 4 hours4 hours

n=2,546n=2,546

Time to Time to treatment treatment >4 hours>4 hours

Time to Time to treatment treatment 4 hours4 hours

Gibson CM, J Am Gibson CM, J Am Coll Cardiol 2004Coll Cardiol 2004

Page 7: Capillary Lumen

87.081.3

0

20

40

60

80

100

Delay in Time from Symptom Onset to Treatment and TIMI Flow Grade post-PCI

3.25

2.75

0

1

2

3

4

n=1,187

p = 0.005

Tim

e fr

om

sx

on

set

to t

reat

men

t (h

rs)

Post-PCI TFG 3

Post-PCI TFG 0/1/2

% P

ost

-PC

I T

FG

3

n=202

25th/75th

Percentile

2 / 4.1

25th/75th

Percentile

2.1 / 5

n=379

p = 0.007

Time to treatment >4 hours

Time to treatment 4 hours

n=1,010

Gibson CM, J Am Coll Cardiol 2004Gibson CM, J Am Coll Cardiol 2004

Page 8: Capillary Lumen

Delay in Time from Symptom Onset to Treatment and Corrected TIMI Frame Count post-PCI

24.4

22.0

0

5

10

15

20

25

n=290

Po

st-P

CI

Co

rrec

ted

TIM

I F

ram

e C

ou

nt

(fra

mes

)

n=796

p = 0.008

Time to treatment >4 hours

Time to treatment 4 hours

25th/75th

Percentile

17 / 37

25th/75th

Percentile

16 / 32

Gibson CM, J Am Coll Cardiol 2004Gibson CM, J Am Coll Cardiol 2004

Page 9: Capillary Lumen

49.9

45.3

0

20

40

60

Delay in Delay in Time from Symptom Onset to Treatment and TIMI Time from Symptom Onset to Treatment and TIMI Myocardial Perfusion Grade post-PCIMyocardial Perfusion Grade post-PCI

3.00

2.67

0

1

2

3

4

n=315n=315

p = 0.017p = 0.017

Tim

e fr

om

sx

on

set

to t

reat

men

t (h

rs)

Tim

e fr

om

sx

on

set

to t

reat

men

t (h

rs)

Post-PCI Post-PCI TMPG 2/3TMPG 2/3

Post-PCI Post-PCI TMPG 0/1TMPG 0/1

% P

ost

-PC

I T

MP

G 2

/3%

Po

st-P

CI

TM

PG

2/3

n=330n=330

25th/75th25th/75th

PercentilePercentile

1.9 / 3.751.9 / 3.75

25th/75th25th/75th

PercentilePercentile

2.1 / 42.1 / 4

n=150n=150

p = 0.33p = 0.33

Time to Time to treatment treatment >4 hours>4 hours

Time to Time to treatment treatment 4 hours4 hours

n=495n=495

Gibson CM, J Am Coll Cardiol 2004Gibson CM, J Am Coll Cardiol 2004

Page 10: Capillary Lumen

Relationship Between Time to Reperfusion, ST-Segment Resolution, Myocardial Blush Scores and Mortality With Primary Percutaneous Coronary Intervention for Acute

Myocardial Infarction: Results from the CADILLAC Trial

Relationship Between Time to Reperfusion, ST-Segment Resolution, Myocardial Blush Scores and Mortality With Primary Percutaneous Coronary Intervention for Acute

Myocardial Infarction: Results from the CADILLAC Trial

Conclusion: Early time to reperfusion is associated with a greater likelihood of successful microvascular reperfusion after primary PCI.

Brodie et al, ACC 2004

30%

35%

40%

45%

50%

55%

60%

65%

70%

<3 hrs 3-6 hrs >6 hrs

Grade 2/3 MB(p=0.007)

Complete STR*(p=0.0002)

*Defined as >70%

•The CADILLAC Trial randomized 2,082 pts with AMI to PTCA vs. stenting +/- abciximab

•Complete STR was associated with a higher frequency of MB (56% vs. 40%, p=0.0007)

•40% of pts with poor STR had good blush scores

•44% of pts with complete STR had poor blush scores

•One year mortality was lowest with optimum microvascular reperfusion (complete STR and Grade 2/3 MB) and highest with poor microvascular reperfusion (0.6% vs. 9.9%, p=0.006)

Page 11: Capillary Lumen

Time-to-treatment and myocardial blushTime-to-treatment and myocardial blushTime-to-treatment and myocardial blushTime-to-treatment and myocardial blush

Time-to-treatment was significantly associated with extent of ST-segment resolution, myocardial blush grade, enzymatic infarct size, and 1-year mortality

Time-to-treatment remained associated with impaired ST-segment resolution (adjusted OR 1.01 [1.01–1.02], p < 0.001) and myocardial blush (adjusted OR 1.01

[1.01–1.02], p < 0.0001) in a MV model

Time-to-treatment was significantly associated with extent of ST-segment resolution, myocardial blush grade, enzymatic infarct size, and 1-year mortality

Time-to-treatment remained associated with impaired ST-segment resolution (adjusted OR 1.01 [1.01–1.02], p < 0.001) and myocardial blush (adjusted OR 1.01

[1.01–1.02], p < 0.0001) in a MV model

Eur Heart J. 2004 Jun;25(12):1009-13Eur Heart J. 2004 Jun;25(12):1009-13