Early Impaired Myocardial Perfusion is Associated with Larger SPECT Infarct Size Patients with a closed myocardium (TMPG 0/1) and patients without complete ST resolution (<70%) had larger infarcts. In a multivariate model, both impaired TMPG and incomplete ST resolution were independently associated with larger infarct size Patients with a closed myocardium (TMPG 0/1) and patients without complete ST resolution (<70%) had larger infarcts. In a multivariate model, both impaired TMPG and incomplete ST resolution were independently associated with larger infarct size n=209 n=111 p<0.001 Median = 13 TMPG ST Resolution p=0.004 Res <70% Res >70% TMPG 0/1 TMPG 2/3 n=108 n=113 Median = 7 Median = 6 Median = 14 % SPECT Infarct Size Circulation 2002

Early Impaired Myocardial Perfusion is Associated with Larger SPECT Infarct Size & Poorer Salvage Median = 7 p=0.004 TMPG 0/1 TMPG 2/3 n=108 n=113 Median = 13 % SPECT Infarct Size Angeja et al; Circulation 2002 In a multivariate model, TMPG 2/3 remained independently associated with a higher salvage index (p=0.001) Dibra et al, JACC 2003:41:

Association of Killip Class and Impaired Myocardial Perfusion “ Patients with heart failure complicating STEMI have impaired myocardial perfusion, which accounts for the poor outcome observed in these patients”. De Luca et al, Circulation 2004;109:

Associaiton of Myocardial Blush with LV Function at 4 Weeks Lepper et al AJC 2001; 88:

Evolution of Myocardial Blush after MI 2.8% Hoffman et al, AJC 2003; 92: Mean of 7.5 months

Evolution of Myocardial Blush after MI 2.8% Hoffman et al, AJC 2003; 92: Mean follow-up 7.5 months

Left Ventricular Function in Relation to Evolution of Myocardial Blush 2.8% Hoffman et al, AJC 2003; 92: Mean follow-up 7.5 months LVEF at mean 7.5 months

Evolution of Thrombolysis in Myocardial Infarction Myocardial Perfusion Grade During Primary Coronary Angioplasty in Acute Myocardial Infarction Predicts Long-Term Recovery of Left Ventricular Function Jaroslaw Zalewski et al, ACC 2004 Reperfusion Pattern 0/1 to 0/1 (I) n=204 2/3 to 0/1 (II) n=11 0/1 to 2 (III) n=133 2/3 to 2 (IV) n=41 0/1 to 3 (V) n=122 2/3 to 3 (VI) n=74 % pts with complete ST resolution 37.3†36.4†45.9†60.9†52.5†72.9† AUC [U/lxh] 3690 ± ± ± 882* 2340 ± 837** 2259 ± 954* 2115 ± 810** EF-24h [%] 42 ± 11† 41 ± 3† 46 ± 9† 45 ± 12† 53 ± 9† 55 ± 8† EF-6m [%] 39 ± 10†,*** 40 ± 3† 45 ± 8† 46 ± 12† 55 ± 9†, †† 59 ± 9†, *** *p<0.01 vs. I, **p<0.01 vs. II, †p<0.001 among I-VI, ††p<0.001 vs. I-IV, ***p<0.01 vs. EF-24h AUC: Area under curve of CK-MB release in the first 48 hours V – MPG improvement from 0/1 to 3, VI – High MPG maintained (2/3 before and 3 after PCI) *p<0.01 vs. I, **p<0.01 vs. II, †p<0.001 among I-VI, ††p<0.001 vs. I-IV, ***p<0.01 vs. EF-24h AUC: Area under curve of CK-MB release in the first 48 hours V – MPG improvement from 0/1 to 3, VI – High MPG maintained (2/3 before and 3 after PCI) Conclusion: Maintaining a high MPG throughout PCI in AMI or achieving a marked MPG improvement are both related to improved ST resolution, smaller areas under the curve for myonecrosis, and better ejection fractions acutely and at 6 month follow-up.

Poorer TMPG is Associated with Higher Coronary Wedge Pressure (Pressure Distal to Stenosis) Coronary Wedge Pressure Closed TMPG 0 Closed TMPG 0 Open TMPG > 0 Open TMPG > 0 28 mm Hg 9 mm Hg

An Elevated LVEDP is Associated with an Occluded Epicardial Artery as well as Impaired TMPG Kirtane et al, J Thromb Thrombolysis 2004 P=0.03 LVEDP >18 LVEDP >18 LVEDP  18 LVEDP  18 n=97 n=427 TFG 0/1 TFG 2/3 P=0.02 n=174 n=217 TMPG 0/1 TMPG 2/3 LVEDP >18 LVEDP >18 LVEDP  18 LVEDP  18