Reiner J S, Lundergan C F, Fung A, Coyne K, Cho S, Israel N, Kazmierski J, Pilcher G, Smith J, Rohrbeck S, Thompson M, Van de Werf F, Ross A M
Division of Cardiology, George Washington University, Washington, DC 20037, USA.
Circulation. 1996 Nov 15;94(10):2441-6. doi: 10.1161/01.cir.94.10.2441.
Patients with early Thrombolysis in Myocardial Infarction (TIMI) grade 2 flow after thrombolysis appear to have outcomes similar to thrombolytic failures. To evaluate the origin and evolution of early TIMI 2 flow, we examined early and late angiographic and ventriculographic data from the Global Utilization of Streptokinase and TPA for Occluded Arteries (GUSTO-1) angiographic study.
Of the 914 patients with both 90-minute and 5- to 7-day catheterizations, 278 patients had TIMI grade 2 flow at 90 minutes. At follow-up, 188 (67%) had improved to TIMI grade 3 flow. At 90 minutes, patients with TIMI grade 2 flow had greater infarct vessel narrowing and a significantly greater incidence of thrombus than patients with TIMI grade 3 flow. At the 5- to 7-day follow-up, patients whose flow had improved from TIMI grade 2 at 90 minutes to grade 3 flow at follow-up had larger-caliber vessels (minimum luminal diameter, 0.99 +/- 0.47 versus 0.84 +/- 0.48 mm; P = .03) and a lower incidence of visible thrombus (26% versus 38%, P = .04) than those with persistent TIMI grade 2 flow. These patients also had a higher mean ejection fraction (57.5 +/- 14.1% versus 52.8 +/- 12.9%, P = .02) and better infarct zone wall motion (-2.1 +/- 1.5 versus -2.6 +/- 1.3 SD per chord, P = .01) at the 5- to 7-day follow-up. Patients in whom flow improved from TIMI grade 2 at 90 minutes to TIMI grade 3 by 5 to 7 days had significantly better left ventricular function than patients with persistent TIMI grade 0, 1, or 2 flow and constituted a group whose left ventricular function was intermediate between those who had no reperfusion (TIMI grades 0 and 1) and those whose reperfusion was complete (TIMI grade 3).
These data suggest that incomplete clot lysis plays a significant role in the pathogenesis of TIMI grade 2 flow. Furthermore, early TIMI grade 2 flow may be sufficient to provide prolonged myocyte viability, which will further recover if flow normalizes.
心肌梗死溶栓治疗（TIMI）后早期血流为2级的患者，其预后似乎与溶栓失败的患者相似。为了评估早期TIMI 2级血流的起源和演变，我们检查了来自全球应用链激酶和组织型纤溶酶原激活剂治疗闭塞动脉（GUSTO-1）血管造影研究的早期和晚期血管造影及心室造影数据。
在914例接受了90分钟及5至7天导管检查的患者中，278例在90分钟时TIMI血流为2级。随访时，188例（67%）改善为TIMI 3级血流。在90分钟时，TIMI 2级血流的患者梗死相关血管狭窄更严重，血栓发生率显著高于TIMI 3级血流的患者。在5至7天的随访中，血流从90分钟时的TIMI 2级改善为随访时的3级的患者，其血管内径更大（最小管腔直径，0.99±0.47对0.84±0.48mm；P = 0.03），可见血栓发生率更低（26%对38%，P = 0.04），而血流持续为TIMI 2级的患者则不然。这些患者在5至7天随访时平均射血分数也更高（57.5±14.1%对52.8±12.9%，P = 0.02），梗死区域室壁运动更好（每节段-2.1±1.5对-2.6±1.3标准差，P = 0.01）。血流在90分钟时从TIMI 2级改善为5至7天时TIMI 3级的患者，其左心室功能明显优于血流持续为TIMI 0、1或2级的患者，构成了一个左心室功能介于无再灌注者（TIMI 0和1级）和再灌注完全者（TIMI 3级）之间的群体。
这些数据表明，不完全的血栓溶解在TIMI 2级血流的发病机制中起重要作用。此外，早期TIMI 2级血流可能足以维持心肌细胞的长期存活，如果血流恢复正常，心肌细胞将进一步恢复。
