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Clinical Significance of Post-Procedural TIMI Flow in Patients With Cardiogenic Shock Undergoing Primary Percutaneous Coronary Intervention

Rajendra H. Mehta, MD, MS, FACC^_*,_*, Fang-Shu Ou, MS^_*, Eric D. Peterson, MD, MPH, FACC^_*, Richard E. Shaw, MA, PhD, FACC, William B. Hillegass, Jr, MD, MPH, FACC, John S. Rumsfeld, MD, PhD, FACC, Matthew T. Roe, MD, MS, FACC^_* American College of Cardiology–National Cardiovascular Database Registry Investigators

^_* Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
Sutter Pacific Heart Centers, San Francisco, California
University of Alabama, Birmingham, Alabama
Denver Medical Veterans Affairs Center, Denver, Colorado

^_* Reprint requests and correspondence: Dr. Rajendra H. Mehta, Box 17969, Duke Clinical Research Institute, Durham, North Carolina 27715 (Email: mehta007{at}dcri.duke.edu).

Objectives: We sought to evaluate the impact of post-primary percutaneous coronary intervention (PCI) Thrombolysis In Myocardial Infarction (TIMI) flow grades in the infarct-related artery (IRA) in patients with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock.

Background: The clinical implications and correlates of post-procedural TIMI flow grades in patients with STEMI and cardiogenic shock treated with primary PCI have not been elucidated.

Methods: We evaluated 4,731 STEMI patients with cardiogenic shock undergoing primary PCI at 567 hospitals participating in the American College of Cardiology–National Cardiovascular Database CathPCI Registry to determine the association of post-procedural TIMI flow grades 0 to 2 with in-hospital outcomes.

Results: Post-PCI TIMI flow grades 0 to 2 in the IRA were present in 14.7% of patients. Compared with patients with TIMI flow grade 3, those with TIMI flow grades 0 to 2 were more likely to undergo coronary artery bypass graft surgery after PCI (20% vs. 5.4%), and develop renal failure (10.1% vs. 5.1%), cardiac tamponade (1.0% vs. 0.5%), and bleeding requiring blood transfusion (35.2% vs. 21.6%). Unadjusted mortality was more than 2-fold higher with TIMI flow grades 0 to 2 versus TIMI flow grade 3 (63% vs. 27%). There was a graded inverse relationship with TIMI flow in the IRA and the adjusted mortality (odds ratio [OR] for TIMI flow grades 0/1: 5.47 [95% confidence interval (CI): 4.13 to 7.24] and for TIMI flow grade 2: 2.63 [95% CI: 2.02 to 3.42] compared with TIMI flow grade 3). Our study also identified factors associated with post-PCI TIMI flow grades 0 to 2.

Conclusions: Lack of procedural success (post-PCI TIMI flow grades 0 to 2 in the IRA) after primary PCI for STEMI among patients with cardiogenic shock is associated with a much higher risk of mortality compared with the risk for patients with normal post-PCI TIMI flow grade 3.

Key Words: acute myocardial infarction • cardiogenic shock • percutaneous coronary interventions • Thrombolysis In Myocardial Infarction flow

Abbreviations and Acronyms   ACC-NCDR = American College of Cardiology–National Cardiovascular Database Registry   CABG = coronary artery bypass graft surgery   IRA = infarct-related artery   PCI = percutaneous coronary interventions   STEMI = ST-segment elevation myocardial infarction   TIMI = Thrombolysis In Myocardial Infarction