Significance of the Thrombolysis in Myocardial Infarction scoring system in assessing infarct-related artery reperfusion and mortality rates after acute myocardial infarction,☆☆,,★★

https://doi.org/10.1016/S0002-8703(97)70107-8Get rights and content

Abstract

Thrombolysis in Myocardial Infarction (TIMI) flow scores were originally devised as semiquantitative angiographic measures of coronary artery perfusion. Several studies have indicated an important relation between different TIMI flow grades at 90 minutes after thrombolysis and clinical outcome. To further evaluate this relation we conducted a metaanalysis of all angiographic, postinfarction trials that studied the relation between individual 90-minute TIMI flow grades and mortality rates. In 4687 pooled patients, the mortality rate was lowest in patients with TIMI grade 3 flow (3.7%) and significantly lower than those with TIMI 2 (6.6%, p = 0.0003; odds ratio 0.55; 95% confidence interval [CI] 0.4% to 0.76%) or TIMI 0/1 flow (9.2%, p < 0.0001; odds ratio 0.38; 95% CI 0.29% to 0.5%). The mortality rate difference between TIMI grade 2 and TIMI grade 0/1 patients was also significant ( p = 0.02; odds ratio 0.7; 95% CI 0.51% to 0.94%). This study confirms the importance of achieving rapid and complete reperfusion after acute myocardial infarction with the best outcome associated with 90-minute TIMI 3 flow. Furthermore, it shows that although TIMI 2 flow (partial perfusion) is not equivalent to TIMI 3 flow, it nevertheless still confers a significant survival benefit compared with TIMI flow 0/1. (Am Heart J 1997;134:62-8.)

Section snippets

Methods

Relevant studies were identified by a systematic MEDLINE search and references from selected studies. In this way, all postinfarction, postthrombolysis angiographic studies that included data on both TIMI grades at 90 minutes after thrombolysis and mortality rates were identified. Only articles that documented mortality rates for the individual TIMI grades were included in the metaanalysis.

Results

Five publications 2, 4, 5, 6, 9 were identified. One trial 4 contained the composite results from five studies, 10, 11, 12, 13, 14 one 5 from four studies, 15, 16, 17, 18 and one 9 from three 19, 20, 21 separate studies. All studies reported the in-hospital to 42-day mortality rate. Of 4687 patients, 1301 (28%) had TIMI 0/1, 996 (21%) had TIMI 2, and 2378 (51%) had TIMI 3 grade flow 90 minutes after initiation of thrombolytic therapy. The number of deaths was 120 (9.2%), 66 (6.6%), and 87

Discussion

This metaanalysis confirms the importance of achieving early and complete infarct-related artery patency for improving the survival rate after an acute infarct, with TIMI 3 flow leading to the lowest mortality rates. There is clearly a significant difference in mortality rate between TIMI 2 and TIMI 3 patients, confirming the general trend seen in recent trials 2, 3, 4, 5, 6 and verifying the view that TIMI 3 flow should be the only patency grade considered to represent reperfusion success.

References (37)

  • RS Badger et al.

    Usefulness of recanalization to luminal diameter of 0.6 millimeter or more with intracoronary streptokinase during acute myocardial infarction in predicting “normal” perfusion status, continued arterial patency and survival at one year

    Am J Cardiol

    (1987)
  • JS Reiner et al.

    Early angiography cannot predict post-thrombolytic coronary reocclusion: observations from the GUSTO angiographic study

    J AM Coll Cardio1

    (1994)
  • P Clemmensen et al.

    Importance of early and complete reperfusion to achieve myocardial salvage after thrombolysis in acute myocardial infarction

    Am J Cardiol

    (1992)
  • JH Chesebro et al.

    Thrombolysis in myocardial infarction (TIMI) trial, phase I: a comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge

    Circulation

    (1987)
  • JL Anderson et al.

    TIMI perfusion grade 3 but not grade 2 results in improved outcome after thrombolysis for myocardial infarction. Ventriculographic, enzymatic, and electrocardiographic evidence from the TEAM-3 Study

    Circulation

    (1993)
  • B Vogt et al.

    Impact of early perfusion status of the infarct-related artery on short-term mortality after thrombolysis for acute myocardiali. Retrospective analysis of four German multicenter studies

    J Am Coll Cardiol

    (1993)
  • RJ Simes et al.

    Link between the angiographic substudy and mortality outcome in a large randomised trial of myocardial reperfusion: importance of early and complete infarct artery reperfusion

    Circulation

    (1995)
  • collaborative overview of randomised trials of antiplatelet therapy. Prevention of death, myocardial infarction and stroke by prolonged antiplatelet therapy in various categories of patients

    BMJ

    (1994)
  • Cited by (36)

    • Management of STEMI in low- and middle-income countries

      2014, Global Heart
      Citation Excerpt :

      In addition, the degree of flow is also important, resulting in the development of the TIMI flow grade (Figure 2) [106]. Mortality is lower among patients with TIMI flow grade 2 or 3, compared with TIMI flow grade 0 to 1, was achieved within 90 min after acute STEMI [107]. Therefore, the goal of reperfusion is not only early reperfusion but also restoration of normal flow (Figures 1 and 2).

    • Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction. A Comprehensive Review of Contemporary Management Options

      2007, Journal of the American College of Cardiology
      Citation Excerpt :

      The early-open-artery theory suggests that benefits of reperfusion in patients with STEMI are directly related to the speed and completeness with which patency of the infarct-related coronary artery is re-established. Mortality has been shown to be lower among patients in whom TIMI flow grade 2 to 3, compared with TIMI flow grade 0 to 1, was achieved within 90 min after acute MI (23). This is strongly supported by clinical studies confirming the important relationship between achieving prompt antegrade coronary flow of the infarct artery and improved clinical outcomes, for both primary PCI (22,24–27) and fibrinolysis (21,28,29).

    • Implantable defibrillator early after primary percutaneous intervention for ST-elevation myocardial infarction: Rationale and design of the Defibrillator After Primary Angioplasty (DAPA) Trial

      2006, American Heart Journal
      Citation Excerpt :

      Two other very strong predictors of long-term mortality are TIMI flow after the primary PCI and LV function. The association between high mortality and impaired TIMI flow was already observed in the thrombolysis trials,17,18 showing that patients with normal epicardial blood flow and myocardial reperfusion have an excellent prognosis,19 but that incomplete reperfusion (TIMI 2 flow) was almost as bad as no reperfusion at all.20-22 Not surprisingly, also after primary PCI, TIMI flow less than 3 is a strong predictor of mortality.14,23

    • Coronary angiography: Beyond coronary anatomy

      2006, Revista Espanola de Cardiologia
    View all citing articles on Scopus

    From the MRC Clinical Sciences Center and Royal Postgraduate Medical School, and the Department of Cardiology, Hammersmith Hospital.

    ☆☆

    Reprint requests: Farzin Fath-Ordoubadi, MRCP, MRC Cyclotron Unit, MRC Clinical Sciences Centre, Hammersmith Hospital, Du Cane Rd., London W12 ONN, United Kingdom.

    E-mail: [email protected] or [email protected]

    ★★

    0002-8703/97/$5.00 + 0 4/1/82102

    View full text