Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort

Gregor Fahrni, Mathias Wolfrum, Giovanni Luigi De Maria, Florim Cuculi, Sam Dawkins, Mohammad Alkhalil, Niket Patel, John C Forfar, Bernard D Prendergast, Robin P Choudhury, Keith M Channon, Adrian P Banning, Rajesh K Kharbanda, Gregor Fahrni, Mathias Wolfrum, Giovanni Luigi De Maria, Florim Cuculi, Sam Dawkins, Mohammad Alkhalil, Niket Patel, John C Forfar, Bernard D Prendergast, Robin P Choudhury, Keith M Channon, Adrian P Banning, Rajesh K Kharbanda

Abstract

Background: Early risk stratification after primary percutaneous coronary intervention (PPCI) for ST-segment-elevation myocardial infarction is currently challenging. Identification of a low-risk group may improve triage of patients to alternative clinical pathways and support early hospital discharge. Our aim was to assess whether the index of microcirculatory resistance (IMR) at the time of PPCI can identify patients at low risk of early major cardiac complications and to compare its performance against guideline-recommended risk scores.

Methods and results: IMR was measured using a pressure-temperature sensor wire. Cardiac complications were defined as the composite of cardiac death, cardiogenic shock, pulmonary edema, malignant arrhythmias, cardiac rupture, and presence of left ventricular thrombus either before hospital discharge or within 30-day follow-up. In total, 261 patients undergoing PPCI who were eligible for coronary physiology assessment were prospectively enrolled. Twenty-two major cardiac complications were reported. Receiver operating characteristic curve analysis confirmed the utility of IMR in predicting complications and showed significantly better performance than coronary flow reserve, the Primary Angioplasty in Myocardial Infarction II (PAMI-II), and Zwolle score (P≤0.006). Low microvascular resistance (IMR ≤40) was measured in 159 patients (61%) of the study population and identified all patients who were free of major cardiac complications (sensitivity: 100%; 95% CI, 80.5-100%).

Conclusions: IMR immediately at the end of PPCI for ST-segment-elevation myocardial infarction reliably predicts early major cardiac complications and performed significantly better than recommended risk scores. These novel data have implications for early risk stratification after PPCI.

Keywords: clinical outcome; microcirculation; myocardial infarction.

© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Figures

Figure 1
Figure 1
Study flowchart. IMR indicates index of microcirculatory resistance; OxAMI, Oxford Study in Acute Myocardial Infarction; PCI, percutaneous coronary intervention; PPCI, primary percutaneous coronary intervention; STEMI, ST‐segment–elevation myocardial infarction.
Figure 2
Figure 2
Diagnostic value to predict early major cardiac complications. Comparison of receiver operating characteristic curves of individual tests to predict early major cardiac complications. IMR performed significantly better than CFR, PAMI‐II, and Zwolle score (DeLong: P=0.006, P=0.001, and P=0.004, respectively). There was no difference among CFR, PAMI‐II, and Zwolle score. Individual cutoff values are marked on the curves. AUC indicates area under the receiver operating characteristic curve; CFR, coronary flow reserve; CI, confidence interval; IMR, index of microcirculatory resistance; PAMI‐II, Primary Angioplasty in Myocardial Infarction II; Sens, sensitivity; Spec, specificity.
Figure 3
Figure 3
Free of major cardiac complications at 30 days. Kaplan–Meier curves comparing percentages of patients free of major cardiac complications at 30 days after primary PCI in groups with low (≤40) and high (>40) IMR. IMR indicates index of microcirculatory resistance; PCI, percutaneous coronary intervention.

References

    1. Floyd KC, Yarzebski J, Spencer FA, Lessard D, Dalen JE, Alpert JS, Gore JM, Goldberg RJ. A 30‐year perspective (1975–2005) into the changing landscape of patients hospitalized with initial acute myocardial infarction: Worcester Heart Attack Study. Circ Cardiovasc Qual Outcomes. 2009;2:88–95.
    1. Steg PG, James SK, Atar D, Badano LP, Blömstrom‐Lundqvist C, Borger MA, Mario C Di, Dickstein K, Ducrocq G, Fernandez‐Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van ‘t Hof A, Widimsky P, Zahger D. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST‐segment elevation. Eur Heart J. 2012;33:2569–2619.
    1. Silverman MG, Morrow DA. Hospital triage of acute myocardial infarction: is admission to the coronary care unit still necessary? Am Heart J. 2016;175:172–174.
    1. Barbash IJ, Kahn JM. Assessing the value of intensive care. JAMA. 2015;314:1240–1241.
    1. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK. ACC/AHA guidelines for the management of patients with ST‐elevation myocardial infarction–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004;110:588–636.
    1. Ahmed N, Layland J, Carrick D, Petrie MC, McEntegart M, Eteiba H, Hood S, Lindsay M, Watkins S, Davie A, Mahrous A, Carberry J, Teng V, McConnachie A, Curzen N, Oldroyd KG, Berry C. Safety of guidewire‐based measurement of fractional flow reserve and the index of microvascular resistance using intravenous adenosine in patients with acute or recent myocardial infarction. Int J Cardiol. 2016;202:305–310.
    1. Aarnoudse W, Fearon WF, Manoharan G, Geven M, van de Vosse F, Rutten M, De Bruyne B, Pijls NHJ. Epicardial stenosis severity does not affect minimal microcirculatory resistance. Circulation. 2004;110:2137–2142.
    1. Ng MKC, Yeung AC, Fearon WF. Invasive assessment of the coronary microcirculation: superior reproducibility and less hemodynamic dependence of index of microcirculatory resistance compared with coronary flow reserve. Circulation. 2006;113:2054–2061.
    1. Fearon WF, Shah M, Ng M, Brinton T, Wilson A, Tremmel JA, Schnittger I, Lee DP, Vagelos RH, Fitzgerald PJ, Yock PG, Yeung AC. Predictive value of the index of microcirculatory resistance in patients with ST‐segment elevation myocardial infarction. J Am Coll Cardiol. 2008;51:560–565.
    1. McGeoch R, Watkins S, Berry C, Steedman T, Davie A, Byrne J, Hillis S, Lindsay M, Robb S, Dargie H, Oldroyd K. The index of microcirculatory resistance measured acutely predicts the extent and severity of myocardial infarction in patients with ST‐segment elevation myocardial infarction. JACC Cardiovasc Interv. 2010;3:715–722.
    1. Payne AR, Berry C, Doolin O, McEntegart M, Petrie MC, Lindsay MM, Hood S, Carrick D, Tzemos N, Weale P, McComb C, Foster J, Ford I, Oldroyd KG. Microvascular resistance predicts myocardial salvage and infarct characteristics in ST‐elevation myocardial infarction. J Am Heart Assoc. 2012;1:e002246 DOI: .
    1. Fearon WF, Low AF, Yong AS, McGeoch R, Berry C, Shah MG, Ho MY, Kim H‐S, Loh JP, Oldroyd KG. Prognostic value of the index of microcirculatory resistance measured after primary percutaneous coronary intervention. Circulation. 2013;127:2436–2441.
    1. De Maria GL, Cuculi F, Patel N, Dawkins S, Fahrni G, Kassimis G, Choudhury RP, Forfar JC, Prendergast BD, Channon KM, Kharbanda RK, Banning AP. How does coronary stent implantation impact on the status of the microcirculation during primary percutaneous coronary intervention in patients with ST‐elevation myocardial infarction? Eur Heart J. 2015;36:3165–3177.
    1. Patel N, Petraco R, Dall'Armellina E, Kassimis G, De Maria GL, Dawkins S, Lee R, Prendergast BD, Choudhury RP, Forfar JC, Channon KM, Davies J, Banning AP, Kharbanda RK. Zero‐flow pressure measured immediately after primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction provides the best invasive index for predicting the extent of myocardial infarction at 6 months: an OxAMI Study. JACC Cardiovasc Interv. 2015;8:1410–1421.
    1. Cuculi F, De Maria GL, Meier P, Dall'Armellina E, de Caterina AR, Channon KM, Prendergast BD, Choudhury RP, Choudhury RC, Forfar JC, Kharbanda RK, Banning AP. Impact of microvascular obstruction on the assessment of coronary flow reserve, index of microcirculatory resistance, and fractional flow reserve after ST‐segment elevation myocardial infarction. J Am Coll Cardiol. 2014;64:1894–1904.
    1. Cuculi F, Dall'Armellina E, Manlhiot C, De Caterina AR, Colyer S, Ferreira V, Morovat A, Prendergast BD, Forfar JC, Alp NJ, Choudhury RP, Neubauer S, Channon KM, Banning AP, Kharbanda RK. Early change in invasive measures of microvascular function can predict myocardial recovery following PCI for ST‐elevation myocardial infarction. Eur Heart J. 2014;35:1971–1980.
    1. Grines CL, Marsalese DL, Brodie B, Griffin J, Donohue B, Costantini CR, Balestrini C, Stone G, Wharton T, Esente P, Spain M, Moses J, Nobuyoshi M, Ayres M, Jones D, Mason D, Sachs D, Grines LL, O'Neill W. Safety and cost‐effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI‐II Investigators. Primary Angioplasty in Myocardial Infarction. J Am Coll Cardiol. 1998;31:967–972.
    1. De Luca G, Suryapranata H, van‘t Hof AWJ, de Boer M‐J, Hoorntje JCA, Dambrink J‐HE, Gosselink ATM, Ottervanger JP, Zijlstra F. Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty: implications for early discharge. Circulation. 2004;109:2737–2743.
    1. DeLong ER, DeLong DM, Clarke‐Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988;44:837–45.
    1. Claessen BEPM, Bax M, Delewi R, Meuwissen M, Henriques JPS, Piek JJ. The Doppler flow wire in acute myocardial infarction. Heart. 2010;96:631–635.
    1. Brush JE, Brand DA, Acampora D, Chalmer B, Wackers FJ. Use of the initial electrocardiogram to predict in‐hospital complications of acute myocardial infarction. N Engl J Med. 1985;312:1137–1141.
    1. Julian DG, Valentine PA, Miller GG. Disturbances of rate, rhythm and conduction in acute myocardial infarction: a prospective study of 100 consecutive unselected patients with the aid of electrocardiographic monitoring. Am J Med. 1964;37:915–927.
    1. Mehta D, Curwin J, Gomes JA, Fuster V. Sudden death in coronary artery disease: acute ischemia versus myocardial substrate. Circulation. 1997;96:3215–3223.
    1. Gorenek B, Blomström Lundqvist C, Brugada Terradellas J, Camm AJ, Hindricks G, Huber K, Kirchhof P, Kuck K‐H, Kudaiberdieva G, Lin T, Raviele A, Santini M, Tilz RR, Valgimigli M, Vos MA, Vrints C, Zeymer U. Cardiac arrhythmias in acute coronary syndromes: position paper from the joint EHRA, ACCA, and EAPCI task force. EuroIntervention. 2015;10:1095–1108.
    1. Niccoli G, Scalone G, Lerman A, Crea F. Coronary microvascular obstruction in acute myocardial infarction. Eur Heart J. 2016;37:1024–1033.
    1. Nijveldt R, Beek AM, Hirsch A, Stoel MG, Hofman MBM, Umans VAWM, Algra PR, Twisk JWR, van Rossum AC. Functional recovery after acute myocardial infarction: comparison between angiography, electrocardiography, and cardiovascular magnetic resonance measures of microvascular injury. J Am Coll Cardiol. 2008;52:181–189.
    1. Husser O, Bodi V, Sanchis J, Nunez J, Lopez‐Lereu MP, Monmeneu JV, Gomez C, Rumiz E, Merlos P, Bonanad C, Minana G, Valero E, Chaustre F, Forteza MJ, Riegger GAJ, Chorro FJ, Llacer A. Predictors of cardiovascular magnetic resonance‐derived microvascular obstruction on patient admission in STEMI. Int J Cardiol. 2013;166:77–84.
    1. Wong DTL, Leung MCH, Richardson JD, Puri R, Bertaso AG, Williams K, Meredith IT, Teo KSL, Worthley MI, Worthley SG. Cardiac magnetic resonance derived late microvascular obstruction assessment post ST‐segment elevation myocardial infarction is the best predictor of left ventricular function: a comparison of angiographic and cardiac magnetic resonance derived measurements. Int J Cardiovasc Imaging. 2012;28:1971–1981.
    1. Mehta RH, Starr AZ, Lopes RD, Hochman JS, Widimsky P, Pieper KS, Armstrong PW, Granger CB. Incidence of and outcomes associated with ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention. JAMA. 2009;301:1779–1789.
    1. Yamamuro A, Akasaka T, Tamita K, Yamabe K, Katayama M, Takagi T, Morioka S. Coronary flow velocity pattern immediately after percutaneous coronary intervention as a predictor of complications and in‐hospital survival after acute myocardial infarction. Circulation. 2002;106:3051–3056.
    1. Barret ML, Smith MW, Elixhauser A, Honigman LS, Pines JM. Utilization of Intensive Care Services, 2011 Statistical Brief #185. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016.
    1. Konkani A, Oakley B. Noise in hospital intensive care units—a critical review of a critical topic. J Crit Care. 2012;27:522.e1–522.e9.

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