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Clinical research

Predictors of suboptimal TIMI flow after primary angioplasty for acute myocardial infarction: results from the HORIZONS-AMI trial

1. Hospital Israelita Albert Einstein, São Paulo, Brazil; 2. Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY, USA; 3. Yale University Medical Center, New Haven, CT, USA; 4. Mount Sinai Medical Center, New York, NY, USA; 5. Weill Cornell Medical College, New York, NY, USA; 6. Istituto Cardiologia, Policlinico S. Orsola, Bologna, Italy; 7. Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin and Campus Virchow-Klinikum, Berlin, Germany; 8. Ospedali Riuniti di Bergamo, Bergamo, Italy; 9. The LeBauer Cardiovascular Research Foundation, Greensboro, NC, USA; 10. Jagiellonian University, Krakow, Poland

Aims: The predictors of TIMI flow <3 after PCI in patients with acute myocardial infarction have not been examined in a contemporary, large-scale multicentre prospective study.

Methods and results: The HORIZONS-AMI trial randomised 3,602 patients with STEMI undergoing primary PCI to bivalirudin (n=1,800) vs. unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor (n=1,802). A total of 3,845 treated lesions (3,362 vessels) were analysed by the core lab; 2,942 vessels (87.5%) and 2,758 patients (87.1%) had final TIMI 3 flow, while 407 (12.9%) had TIMI flow <3. The independent predictors of TIMI flow <3 were age (OR 1.23 per 10-year increase; 95% CI: 1.12 to 1.35; p<0.0001), anterior MI (OR 1.65; 95% CI: 1.33 to 2.05; p<0.0001), baseline TIMI flow grade 0/1 (OR 2.79; 95% CI: 2.14 to 3.62; p<0.0001), and lesion length (OR 1.05 per 10 mm increase; 95% CI: 1.02 to 1.09; p=0.005). The three-year mortality of patients in whom final TIMI 3 flow was achieved was significantly lower than that of patients in whom TIMI 3 flow was not achieved (5.5% vs. 10.5%; p<0.0001).

Conclusions: In this large-scale, randomised trial, failure to restore normal TIMI flow after primary PCI in STEMI occurred in 12.9% of patients, and was associated with patient-related factors (age), anatomical factors (anterior MI location), and angiographic factors (baseline TIMI 0/1 flow and lesion length). Failure to achieve TIMI 3 flow continues to be a powerful predictor of mortality after primary PCI in the contemporary era. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00433966.

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