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StatPearls . Treasure Isl& (FL): StatPearls Publishing; 2021 Jan-.



Ađáng yêu myocardial infarction (MI) is the leading cause of death worldwide. It has been widely accepted that it is due to lớn the insufficient blood supply lớn the cardiac tissue. In an attempt khổng lồ intervene, physicians in the 1970s studied ligation of canine coronary arteries and documented prevention of necrosis with ligation release under appropriate time limits. Initial therapeutic reperfusion was established using intravenous and intracoronary thrombolytic agents, and several studies were conducted on them.<1><2><3><4>

Clinical Significance

In 1983, the TIXiaoMi MI (Thrombolysis in Myocardial Infarction) study group (Brigsay mê và Women"s Hospital, Boston, Massachusetts) chose khổng lồ conduct a randomized, double-blind, multicenter study to assess the efficacy of intravenous (IV) streptokinase. Phase 1 studied IV streptokinase & IV tPA (tissue plasminogene activator) và assessed "recanalization of the totally occluded artery 90 minutes after the start of drug infusion." For this study, the TIMI Coronary Grade Flow was established to lớn ensure a uniform và consistent method of recording epicardial perfusion on coronary arteriography. TIXiaoMi MI grade flow 0 represented total occlusion, và TIMI grade flow 3 represented normal epicardial perfusion. Images were evaluated at the clinical site & later at a central radiographic lab lớn further ensure consistency. In 1985, due to lớn statistically significant differences in recanalization rates with tPA over streptokinase, phase 1 of the study was stopped.<5><6><7>

Definitions of Perfusion

Grade 1 (penetration without perfusion): The contrast material passes beyond the area of obstruction but “hangs up” & fails khổng lồ opacify the entire coronary bed distal khổng lồ the obstruction for the duration of the cine-angiographic filming sequence.
Grade 2 (partial perfusion): The contrast material passes across the obstruction and opacifies the coronary bed distal lớn the obstruction. The rate of entry of the contrast material inkhổng lồ the vessel distal to lớn the obstruction or the rate of clearance from the distal bed is perceptibly slower than its entry into or clearance from comparable areas not perfused by the previously occluded vessel—e.g., the opposite coronary artery or the coronary bed proximal khổng lồ the obstruction.
Grade 3 (complete perfusion): Antegrade flow inlớn the bed distal to the obstruction occurs as promptly as antegrade flow inkhổng lồ the bed proximal khổng lồ the obstruction, and clearance of contrast material from the involved bed is as rapid as clearance from an uninvolved bed in the same vessel or the opposite artery.

Limitations of the TIXiaoMi MI grade flow include obVPS variability, and it only provides categorical values instead of continuous ones. However, the TIMI study group also developed additional scoring systems. TIXiaoMi MI frame count (TFC) measures the number of cine-angiographic frames khổng lồ reach standardized distal landmarks, thus providing a quantitative sầu assessment of epicardial flow. It was established to lớn enhance the reproducibility of the angiographic assessment.

As TIXiaoMI grade flow & TFC assess epicardial flow, TIXiaoMI myocardial perfusion (TMP) grade was developed khổng lồ assess microvascular perfusion. Using myocardial contrast echocardiography, a visual assessment is made of contrast mật độ trùng lặp từ khóa in the infarcted myocardium after reperfusion therapy. It is scored 0 to 3, with “0 representing no apparent tissue-cấp độ perfusion & TMP.. 3 indicating normal perfusion.” It has been shown that despite having a TIXiaoMI grade flow of 3, some patients have sầu no reflow in the myocardium (TMPhường 0). TMP has also been shown khổng lồ be an independent predictor of mortality.

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Definitions of TMPhường Grades

TMPhường Grade 0: Failure of dye lớn enter the microvasculature. Either minimal or no ground-glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit artery, indicating lack of tissue-level perfusion.
TMP.. Grade 1: Dye slowly enters but fails khổng lồ exit the microvasculature. There is the ground-glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit lesion that fails lớn clear from the microvasculature, và dye staining is present on the next injection (approximately 30 seconds between injections).
TMPhường Grade 2: Delayed entry & exit of dye from the microvasculature. There is a ground-glass appearance or opacification of the myocardium in the distribution of the culprit lesion that is strongly persistent at the end of the washout phase (i.e., the dye is strongly persistent after three cardiac cycles of the washout phase & either does not or only minimally diminishes in intensity during washout).
TMP Grade 3: Normal entry and exit of dye from the microvasculature. There is the ground-glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit lesion that clears normally và is either gone or only mildly/moderately persistent at the completion of the washout phase (i.e., dye is gone or is mildly/moderately persistent after 3 cardiac cycles of the washout phase and noticeably diminishes in intensity during the washout phase), similar to that in an uninvolved artery. The blush that is of only mild intensity throughout the washout phase but fades minimally is also classified as grade 3.

The TIMI Coronary Grade Flow is an effective & well-studied grading system of coronary reperfusion on an angiogram. Achieving earlier TIXiaoMi MI grade 3 flow has been correlated with improved survival in both reperfusions with thrombolysis or primary percutaneous coronary intervention (PCI). Additionally, combining TIXiaoMi MI grade flow and TMP can stratify patients at very low risk và high risk for mortality post-STEXiaoMI. Proven a useful tool in patients with adễ thương XiaoMI, the TIMI grade flow is used routinely.<9><10>

Nursing, Allied Health, and Interprofessional Team Interventions

Since the initial TIXiaoMi MI 1 study, the TIMI flow grading system has been used globally to lớn measure epicardial flow and is considered the “gold standard” Mã Sản Phẩm compared to lớn other modalities. It has been studied to show the predictability of clinical outcomes. The global utilization of streptokinase và tissue plasminoren activator for occluded coronary arteries (GUSTO) studied TIMI grade flows và 30-day mortality. The original investigators analyzed data from the GUSTO trial & noted “a laông xã of patency at 90 minutes (TIMI grade 0 or 1) was associated with mortality of 8.9 percent, and patency (TIXiaoMI grade 2 or 3) with mortality of 5.7 percent (P.. = 0.04). The mortality rate aý muốn patients with TIXiaoMi MI grade 2 flow was 7.4 percent, và the rate aước ao those with TIXiaoMI grade 3 flow was 4.4 percent (P = 0.08). The difference between the mortality rate associated with grade 3 và the rate associated with grade 0 or 1 was significant (P = 0.009).”

Additionally, patients with TIXiaoMI 3 before angioplasty are less likely to lớn develop left ventricular complications và have improved survival. Other examples of clinical significance include a demonstration of increased mortality risk in a patient with low TIXiaoMI grade flow (0-2) post-PCI for STEMI among mỏi patients with cardiogenic shoông xã, compared khổng lồ normal post-PCI TIXiaoMi MI grade flow.

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