Persistence of systolic coronary flow reversal predicts irreversible dysfunction after reperfused anterior myocardial infarction

Abstract

Objective: To investigate serial assessments of systolic coronary flow reversal in the infarct related artery for predicting poor left ventricular functional recovery after reperfused acute myocardial infarction. Setting: Regional hospital. Patients and methods: 49 patients with anterior acute myocardial infarction had transthoracic Doppler echocardiography to record coronary flow velocity in the left anterior descending coronary artery immediately after successful primary coronary angioplasty (day 0), and at 48 hours, one week, and three weeks. Main outcome measures: Coronary flow velocity at each time point; regional wall motion score index (RWMSI) at day 0 and at three weeks. Irreversible dysfunction was defined as a decrease in RWMSI to < 0.22. Results: Measurements of coronary flow velocity could be made in 45 patients. Patients were divided into three groups: no systolic flow reversal (group 1, n = 27), systolic flow reversal observed only on day 0 (group 2, n = 8), and systolic flow reversal persisting until 48 hours (group 3, n = 10). Although baseline RWMSI was similar among the three groups, the value at three weeks was significantly higher in group 3 than in the other two groups. In predicting irreversible dysfunction, the persistence of systolic flow reversal up to 48 hours had a higher positive predictive value (100%) than the presence of systolic flow reversal on day 0 (67%, p < 0.04). The negative predictive value of systolic flow reversal at 48 hours (83%) was comparable in accuracy to the presence of systolic flow reversal on day 0 (85%, NS). Conclusions: In reperfused anterior acute myocardial infarction, serial assessment of coronary flow velocity in the left anterior descending coronary artery is feasible using transthoracic Doppler echocardiography, and the persistence of systolic flow reversal at 48 hours is a more specific marker of irreversible dysfunction than peak creatine kinase or diastolic deceleration time. P rimary coronary angioplasty is an effective method for improving prognosis in patients with acute myocardial infarction.1 However, successful angioplasty does not always guarantee adequate tissue perfusion of the myocardium distal to the previously occluded vessel.2 3 Some patients develop the no reflow phenomenon, which is associated with sustained left ventricular dysfunction, left ventricular remodelling, and subsequent poor outcome.4 5 The characteristic coronary flow velocity profile of systolic flow reversal is observed immediately after reperfusion has been achieved in patients with the no reflow phenomenon 6 and is associated with poor functional recovery.7 Although early prediction of the recovery of left ventricular dysfunction is important for identifying high risk patients and selecting the appropriate therapeutic strategy, many confounding factors-including coronary hyperaemia, reperfusion injury, and microvascular stunningaffect coronary flow to the previously ischaemic myocardium over time. 8Transthoracic Doppler echocardiography may be suitable for the serial as...

Echocardiographic assessment of coronary flow velocity and coronary flow velocity reserve in ischemic cardiac disease

“…Serial assessment of the CFV profi le after acute anterior wall myocardial infarction is possible using transthoracic Doppler echocardiography. We demonstrated that the persistence of systolic fl ow reversal at 48 hours after the infarction is a more specifi c marker than the presence of systolic fl ow reversal immediately after coronary reperfusion for predicting subsequent irreversible dysfunction [ 29 ] ( Fig. 5 ).…”

“…Although the presence of systolic fl ow reversal immediately after coronary reperfusion assessed by an invasive Doppler guidewire in patients with acute myocardial infarction generally refl ects poor functional recovery, many confounding factors (eg, coronary hyperemia, reperfusion injury, and microvascular stunning) affect the CFV profi le to the previously ischemic myocardium over time [ 29 ]. Serial assessment of the CFV profi le after acute anterior wall myocardial infarction is possible using transthoracic Doppler echocardiography.…”

Assessment of Coronary Flow During Stress Testing: Does it Add Diagnostic and Prognostic Value?

“…Persistent early systolic reverse coronary flow and a rapid deceleration time of coronary diastolic flow using TTE (< 600 ms) predicts poor functional recovery in AMI after primary coronary angioplasty [44].…”

Left ventricular remodeling in the elderly with acute anterior myocardial infarction treated with primary coronary intervention

“…Our study population was evaluated at a time interval after the acute event that should have been sufficient to allow a complete restoration of microvascular function, which, in the acute phase of a STEMI, may be structurally and functionally abnormal for microembolization and impaired vasodilator reserve, even independently of the presence of a no-reflow phenomenon [30][31][32]. In our groups of patients showing a wide range of EF and CFR values, the relationship between these two parameters was maintained, including also in subjects in whom we could not exclude a no-reflow phenomenon in the acute phase from the presence of a very low CFR value (under 1.6).…”