Methodologic drift in the assessment of TIMI grade 3 flow and its implications with respect to the reporting of angiographic trial results☆,☆☆
Section snippets
Methods
The data are drawn from 3 recent TIMI trials: TIMI 10A, 10B, and 14. TIMI 10A was a nonrandomized, open-label, dose escalation study of 8 ascending doses of TNK (5, 7.5, 10, 15, 20, 30, 40, and 50 mg given intravenously over 5 to 10 seconds) in 113 patients.4 TIMI 10B was a randomized trial of 30-, 40-, and 50-mg doses of TNK versus front-loaded recombinant tissue plasminogen activator (r-TPA) in 853 patients.5 TIMI 14 is a trial of abciximab alone versus abciximab in combination with low-dose
Results
To place the rate of TIMI grade 3 flow reported by the TIMI angiographic core laboratory in context, a pooled analysis involving 1492 patients from angiographic trials of front-loaded TPA reported to date reveals an overall 90-minute patency rate of 82% (60% rate of TIMI 3 flow and 22% rate of TIMI 2 flow),6, 10, 11, 12, 13, 14, 15, 16 as shown in Figure 1.
Discussion
We have shown that even when the same definition is applied by angiographers, there is a substantial interobserver variability in the classification of the TIMI flow grades.7 The rate of agreement between an angiographic core laboratory and clinical centers is good in determining whether a culprit artery is either open or closed (κ = 0.84).7 In contrast, the rate of agreement is only moderate when assessing TIMI grade 3 flow (κ = 0.55) and is actually poor in the assessment of TIMI grade 2 flow
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Cited by (31)
B-Type natriuretic peptide levels predict extent and severity of coronary artery disease in non-ST elevation acute coronary syndrome and normal left ventricular function
2014, Indian Heart JournalCitation Excerpt :Coronary stenosis was quantified using validated quantitative coronary angiography by the consensus opinion of two experienced interventional cardiologists with >50% diameter stenosis considered as significant. Assessment of epicardial coronary flow was done using the TIMI flow grade according to established methods.11 The Gensini Score (GS) was used to assess the burden of coronary arteriosclerosis.12
B-type natriuretic peptide levels predict extent and severity of coronary disease in non-ST elevation coronary syndromes and normal left ventricular systolic function
2011, Regulatory PeptidesCitation Excerpt :Coronary stenosis was quantified using validated quantitative coronary angiography. Assessment of epicardial coronary flow was done using the TIMI flow grade according to previously described methods [11]. The Gensini score (GS) was used in the present study to assess the burden of coronary arteriosclerosis [12].
Initial patency of the infarct-related artery in patients with acute ST elevation myocardial infarction is related to platelet response to aspirin
2010, International Journal of CardiologyCitation Excerpt :We had only 6% of patients with initial TIMI-3 flow which is much lower then 16% reported by Stone et al. [1]. This can be explained by their definition of TIMI-3 flow, where “complete filling of the distal vessel by the third cardiac cycle” overestimates the proportion of these patients when compared to the original TIMI definition that was used in our study [7]. Our results indicate that patients with stronger response to aspirin as assessed by AA induced aggregation in ASPI-test have significantly higher initial coronary flow when compared to those with suboptimal platelet response.
Coronary angiography: Beyond coronary anatomy
2006, Revista Espanola de CardiologiaA union in reperfusion: The concept of facilitated percutaneous coronary intervention
2000, Journal of the American College of CardiologyMultimodality reperfusion therapy for acute myocardial infarction
2000, American Heart JournalCitation Excerpt :The use of full-dose fibrinolytic therapy along with percutaneous transluminal coronary angioplasty and/or stenting in the current era has recently been found to provide incremental benefits in vessel patency over the use of fibrinolytic therapy alone. Data gathered in the TIMI core laboratory show that TIMI grade 3 flow is improved by the addition of PCI to fibrinolysis, from 60% for accelerated TPA alone up to 83% in patients receiving fibrinolytic therapy plus adjunctive stenting.44 The second pre-PCI therapy studied has been GP IIb/IIIa inhibition.
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Reprint requests: C. Michael Gibson, MS, MD, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212.
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