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Unstable Angina: Embolism Can Occur Prior to PCI

Unstable Angina: Embolism Can Occur Prior to PCI. Thrombus in proximal RCA. Stain of muscle before injection begins: TIMI Myocardial perfusion grade 1. CM Gibson 2002. GUSTO 2B: ST Depression A High-Risk Patient Population. ST . P  0.001. ST . T-wave inversion. CM Gibson 2002.

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Unstable Angina: Embolism Can Occur Prior to PCI

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  1. Unstable Angina: Embolism Can Occur Prior to PCI Thrombus in proximal RCA Stain of muscle before injection begins: TIMI Myocardial perfusion grade 1 CM Gibson 2002

  2. GUSTO 2B: ST DepressionA High-Risk Patient Population ST  P  0.001 ST  T-wave inversion CM Gibson 2002

  3. Unstable Angina: Platelet Plugging of the Capillaries “The results support the view that platelet aggregates in the myocardium represent an embolic phenomenon and are a potential cause of unstable angina. The association of myocardial necrosis with such emboli could precipitate sudden death from ventricular fibrillation.” From: Intramyocardial platelet aggregation in patients with unstable angina suffering sudden ischemic cardiac death Davies MJ, Circulation 1986

  4. UA / Non STEMI versus STEMIMechanisms of Long Term Outcomes Necrosis by closed Muscle ST  Arrhythmias CHF Death Necrosis by closed Artery ST  CM Gibson 2002

  5. Correlation Between Elevated Cardiac Enzymes at Presentation and Long-term Mortality % mortality at 1 year + Cardiac Troponin T at Baseline(n=559) 14.1% P<0.0001 – Cardiac Troponin T at Baseline(n=474) 4.5% Newby LK et al. Circulation. 1998; 98: 1853-1859.

  6. % % % Mortality at 42 Days % % % 831 174 148 134 50 67  Association of Troponin Elevation with Risk of Mortality in Acute Coronary Syndromes

  7. Audience Poll • What is a powerful angiographic predictor of the patient’s troponin status? Circulation 2002;106:202-207

  8. Answer: Even when epicardial TIMI flow grade and the presence of thrombus were adjusted for, the presence of a closed microvasculature was independently associated with tnT elevation in a multivariate model (O.R. 1.79, p=0.017). Circulation 2002;106:202-207

  9. Tissue Perfusion Predicts Troponin Release P=0.021 P=0.007 P=0.0003 P=0.03 % Normal TMPG 3 % Thrombus % Stenosis % Vessel Occlusion tnT - tnT + tnT - tnT + tnT - tnT + tnT - tnT + Even when epicardial TIMI flow grade and the presence of thrombus were adjusted for, the presence of a closed microvasculature was independently associated with tnT elevation in a multivariate model (O.R. 1.79, p=0.017). Circulation 2002;106:202-207

  10. Event Free Survival is Associated with Tissue Level Perfusion in UA / Non Q Wave MI: TACTICS – TIMI 18 TMPG 2/3 Pre or Post-PCI Log rank p=0.026 TMPG 0/1 Pre & Post PCI Event Free Survival Days Circulation 2002;106:202-207

  11. TMPG and Maximum CK-MB 24 Hours Post-stent All Patients Have TIMI 3 Flow at Completion of Stenting p = 0.002 41.2% Maximum CK-MB >2x ULN (%) 4.2% 1/24 14/34 Gibson, Am Heart J 2002

  12. The Time Dependent Open Artery and Open Microvascular Hypothesis Plaque rupture/erosion/fissure Occlusive STEMI Non – Occlusive UA / NSTEMI Platelet thrombus Vasoconstriction Embolization TIMI 2 Flow Inflammation TIMI 0 Flow Edema Impaired tissue level perfusion Time Dependent Necrosis GP 2b3a Antithrombin + GP 2b3a + Troponin / CK Arrhythmias / CHF CM Gibson 2002 Death

  13. Conclusions: • The source of Tn and CK is the muscle • Tn positive: Poorer muscle perfusion before PCI1 • CK positive: Poorer muscle perfusion post PCI2 • Poorer TMPG before PCI: worse outcomes at 6 months in TACTICS1 • Poorer TMPF after PCI: worse outcomes at one year in ESPRIT2 2. Gibson, Am Heart J 2002 1. Circulation 2002;106:202-207

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