Serial Study Of Improving Myocardial Tissue Perfusion In Emergent Percutaneous Coronary Intervention In Acute Myocardial Infarction

Objective To study the relative factors of abnormal myocardial tissue perfusion after emergent percutaneous coronary intervention (PCI) in ST segment elevation acute myocardial infarction patients (STEMI), analyse the influence of abnormal myocardial tissue perfusion to ventricular function and prognosis, and evaluate the safety and efficacy of proximal aspiration devices and prophylactic intracoronary injection diltiazem with nitroglycerin to improve tissue perfusion in above patients.Methods From January of 2001 to April of 2007, 239 consecutive STEMI patients who underwent emergent PCI were enrolled. They were assigned to poor flow group (abnormal myocardial tissue perfusion group, TIMI grade ≤2, n_A =33) and normal flow group (TIMI grade =3, n_B =206). It was compared between them in basic clinical data, coronary angiography data and treatment data. Multivariate Logistic regression analyse was used to identify independent relative factors of poor flow among those that was significantly difference in the base data between two groups.Serum markers of cardiac damage, ST segment resolution index and echocardiography data were compared to evaluate ventricular function, and serious complication, major adverse cardiac events (MACE) and rehospital events were compared to evaluate clinical prognosis between two groups.Patients who using proximal aspiration devices before stenting were enrolled in aspiration group (n_C=39), and those who were similar in baseline and CAG but only received routine PCI in the same period were enrolled in the control group (n_D =39). TIMI grade, MBG grade and cTFC were compared to evaluate myocardial tissue perfusion. Meanwhile it was compared between two groups inother basic clinical and CAG data, ventricular function and prognosis data.The enrolled cases were assigned to receive intracoronary diltiazem with nitroglycerin (n_E=100) and none of them (n_F=130) just before stenting. It was compared between two groups in basic clinical data, CAG data, myocardial tissue perfusion, ventricular function and prognosis data.Results Single-variable analysis showed that preinfarction angina(15.15% vs 39.80%),higher Killip grade(3-4grade: 27.27% vs 7.77%),longer time from symptom onset to first ballooning(442±118min vs 377±115min), Serum markers of cardiac damage before PCI(CK-MB:287.14±159.62u/L vs 226.64±131.73 u/L; TnT:9.12± 10.21 ug/dl vs 5.62±7.01 ug/dl) and prophylactic intracoronary injection vasodilators (27.27% vs 48.54%) were difference significantly(P < 0.05). Multivariate Logistic regression analysis demonstrated that no preinfarction angina, higher Killip grade and longer interval from symptom onset to first ballooning were the predictable risk factors of poor flow.Poor flow group had less TIMI 3 grade(60.61% vs 95.15%), less MBG 3 grade(36.37% vs 83.01%) and more cTFC(56.93±24.31 frame vs25.92±17.31 frame) than normal flow group; poor flow group had worse cardiac function and prognosis,such as the area under the curve of CK-MB ( AUC_CK-MB ) (807.13±656.66 u·d/L vs 572.63±485.16 u·d/L), ST segment resolution index (STRI)(63.22±29.21% vs 74.23±26.11%), EF(47.11±21.11% vs 57.56±9.812%), hospital-term MACE(24.24% vs 4.85%), cardial rehospital events(48.48% vs 20.87%) and total MACE(36.36% vs 14.56%)(P < 0.05).With the similar basic data, when proximal aspiration devices were used, aspiration group had more MBG 3 grade(69.23% vs 46.15%) and less cTFC(29.91±11.71 frame vs 38.91±17.81 frame) than the control group; and they had better cardiac function and prognosis,such as AUC_CK-MB(408.41±312.91 u·d/L vs 723.01±507.02u·d/L),STRI (78.31±22.10% vs 58.80±28.71%), EF(62.71±13.01% vs 52.31±21.91%) and total MACE(10.26% vs 28.211%)(P < 0.05).When prophylactic intracoronary injecting diltiazem with nitroglycerin, injection group had more MBG 3 grade(79.00% vs 62.30%) and lower cTFC frame (34.41±11.30 frame vs 38.91±17.20 frame) than the control group; injection group had better cardiac function and prognosis,such as AUC_CK-MB (496.11±441.11u·d/L vs 656.11±544.90u·d/L) , STRI(77.81±26.12% vs 67.21±27.10%), EF(60.11±9.21% vs 53.61±12.01%),cardial rehospital events(17.00% vs 31.53%) and total MACE(11.00% vs 22.31%)(P < 0.05).Conclusion No preinfarction angina, higher Killip grade, and longer interval from the symptom onset to first ballooning could promote abnormal myocardial tissue perfusion. Abnormal myocardial tissue perfusion aggravates ventricular function seriously, such as ST segment resolute much slowly, Serum markers of cardiac damage release more and ejection fraction decrease. Abnormal myocardial tissue perfusion increase total MACE and rehospital events significantly. Application of proximal aspiration devices during emergent PCI in STEMI patients with much thrombosis and prophylactic intracoronary injection diltiazem with nitroglycerin in STEMI patients are safe and effective, which can improve distal myocardium perfusion, make the resolution of ST segment faster, decrease myocardial damage and prevent cardiovascular events.