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New tools for assessing microvascular obstruction in patients with ST elevation myocardial infarction
  1. J A de Lemos,
  2. J J Warner
  1. Cardiovascular Division and Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
  1. Correspondence to:
    James A de Lemos
    MD, UT Southwestern Medical Center, 5323 Harry Hines Blvd, HA 9.133, Dallas, TX 75390-9047, USA;

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While early and sustained patency of the infarct related artery is necessary following ST elevation myocardial infarction, tissue and microvascular perfusion must also be restored. Effective tools for assessing microvascular obstruction are therefore essential

A primary goal of therapy in ST elevation myocardial infarction (MI) has been to restore normal blood flow in the occluded epicardial coronary artery as rapidly as possible. The “early open artery hypothesis” is supported by large datasets demonstrating a stepwise association between faster post-reperfusion epicardial blood flow and lower subsequent mortality.1 A series of studies, using a variety of invasive and non-invasive imaging techniques, has shown that while early and sustained patency of the infarct related artery (IRA) is necessary, it is not sufficient to ensure optimal outcomes after reperfusion therapy: tissue and microvascular perfusion must also be restored.

Using myocardial contrast echocardiography (MCE), a technique that was novel at the time, Ito and colleagues demonstrated microvascular “no reflow” among ~25% of patients with normal epicardial blood flow following primary percutaneous coronary intervention (PCI) for acute MI.2 These patients were found to be at high risk for subsequent death and heart failure. Using tools as diverse as intracoronary Doppler, cardiac MRI, nuclear scintigraphy, and contrast angiography, it has been shown that microvascular impairment is associated with an adverse prognosis, even if epicardial blood flow has been restored.3


A less sophisticated technique, measurement of the degree of resolution of ST elevation on the surface 12 lead ECG, has long been used to assess success or failure of reperfusion therapy. As the definition of successful reperfusion has evolved, so has understanding of the information provided by the ECG.4 When assessed 90–180 …

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