ORIGINAL ARTICLE

Pak Heart J

OUTCOME OF PRIMARY PERCUTANEOUS CORONARY

INTERVENTION WITH EARLY AND LATE ST
RESOLUTION - EARLIER IS BETTER!

Muhammad Tariq Farman1, Abdul Malik2, Qurban Ali Rahu3, Jawaid Akbar Sial4,
Naveedullah Khan5, Waheed Murad Shaikh6, Tahir Saghir7, Khan Shah Zaman8

1
Department of Cardiology, Jinnah
Medical College Hospital (JMCH), ABSTRACT
Karachi, Pakistan
2 Objective: To compare the outcome of Primary PCI in patients presenting with
Depar tment of Cardiovascular
Surgery, Lady Reading Hospital, early ST resolution versus those presenting late ST resolution after the procedure.
Peshawar Methodology: This observational prospective study was conducted in the
3
Department of Cardiology, People Catheterization Laboratory of a Tertiary Care Cardiovascular Centre of Pakistan.
Medical University, Nawabshah, Those patients who under went primary PCI were enrolled. All patients were pre
Pakistan treated with Aspirin 300 mg, and Clopidogrel 600mg. Platelet glycoprotein IIb IIIa
4
Department of Cardiology, Chandka inhibitor was given in the Catheterization Laboratory before the commencement
Medical College Hospital, Larkana,
Pakistan of procedure. Primary PCI was done in a standard fashion. Procedural details,
5-8 angiographic and electrocardiographic signs were recorded after PCI and clinical
Department of Cardiology, NICVD,
Karachi, Pakistan follow up was documented up to 1 year.
Address for Correspondence: Results: A total of 150 consecutive patients underwent primary PCI. 112 patients
Dr. Muhammad Tariq Farman, showed ST resolution within 60 minutes while 38 patients showed ST resolution
after 60 minutes. Patients with early ST resolution showed significant procedural
C-45, Block-2, KAECHS, Karachi, success (100 % vs. 94.7 %; P=0.014), and stable follow up at 30 days (92 % vs.
Pakistan 50 %; P= <0.001) and one year (88.3 % vs. 60.6 %; P=< 0.001). Mortality at
E-Mail: tariqfarman@yahoo.com 30 days was significantly lower (0.9% vs. 7.9 %; P=0.019) in patients with early
ST resolution while coronary artery bypass surgery was also significantly lower
Date Received: November 17, 2014
at 30 days (1.7 % vs. 15.8 %; P=0.001) and one year (2.7 % vs. 15.8 %;
Date Revised: December 23, 2014
P=0.004). Patients with late ST resolution were significantly aged (54.5±8.1 vs.
Date Accepted:December 26, 2014
50.4±12.9; P=0.023), more diabetic (39.5 % vs. 19.6 %; P=0.014), having
Contribution longer (>120 minutes) chest pain to ER time (34.2 % vs. 17.9%; P=0.03), and
All the authors contributed significantly having diffusely diseased vessels (73.7% vs. 52.7%; P=0.023). Three vessel
to the research that resulted in the disease was also more frequently seen in patients with late ST resolution (36.9%
submitted manuscript. vs. 17.9%; P=0.015).
All authors declare no conflict of Conclusion: Outcome of patients showing early ST resolution is significantly
interest. better than those showing late ST resolution. Elderly, diabetes, longer chest pain
This article may be cited as: Farman to ER time and diffuse three vessel disease are associated with late ST resolution.
MT, Malik A, Rahu QA, Sial JA, Khan N, Key Words: Outcome, Primary Percutaneous Coronary Intervention, ST
Shaikh WM, et al. Outcome of primary Resolution
percutaneous coronary intervention
with early and late ST resolution -
earlier is better! Pak Hear t J
2014;48(01):42-47.

Pak Heart J 2015 Vol. 48 (01) : 42-47 42

 OUTCOME OF PRIMARY PCI WITH EARLY AND LATE ST RESOLUTION - EARLIER IS BETTER!

INTRODUCTION of hospital admission, those who were diagnosed as Non ST

elevation Myocardial Infarction (NSTEMI) and those
Primary Percutaneous coronary intervention (PCI) is presenting beyond 24 hours with resolved symptoms were
considered a preferable treatment of acute ST elevation excluded from the study. Patients with history of MI in the
myocardial infarction (STEMI).1,2 It is now being done same territory and those whose surface ECG could not be
successfully in many tertiary care centers of Pakistan.3,4 evaluated due to persistent electrical problem like left bundle
Although the restoration of epicardial coronary flow with branch block, paced or ventricular rhythm, WPW syndrome
primary PCI is achieved in majority of patients and it is far etc were also excluded from the study.
better than the pharmacological revascularization.1,2
Primary PCI was performed in standard method using a
However, considerable number of patients showed
variety of guiding catheters, coronary wires, balloons and
suboptimal and unsatisfactory results manifested by
stents. The majority of interventions were performed
unstable hemodynamic status, persistence of symptoms,
through the femoral route. However, the choice of access
abnormal myocardial blush and incomplete or absent ST
was on discretion of operators and considerable number
resolution on surface electrocardiogram (ECG).5-8
(18 %) of interventions was performed through radial route.
Absent or incomplete ST resolution after PCI is a strong All patients received 5000-10,000 units of intravenous
predictor for adverse events and abnormal left ventricular unfractionated heparin, Aspirin 300 mg, clopidogrel 600 mg
function. In contrast, patients with early ST resolution show (loading dose), and Platelet glycoprotein IIb IIIa inhibitor.
smaller infarct size and lower incidence of cardiac death at Thrombus extraction catheter (Export catheter 6-F;
one year. These differences remained significant even after Medtronic Corporation, USA) was used when obvious clot
adjustment of myocardial blush grade (MBG).5-9 was visible in the infarct related artery (thrombus class 2-5).
Intracoronary nitroprusside and adenosine use were at the
In our resource limited country, the average age of patients
discretion of operators. All patients were prescribed Aspirin
suffering STEMI is younger than the western population.3,4
300 mg, Clopidogrel 75 mg and Atorvastatin 20-40 mg /
Moreover, overall risk profile is poorer considering the fact of
Rosuvastatin 10-20 mg daily at the time of discharge from
having more uncontrolled diabetes and hypertension.10 In
the hospital.
addition, due to lack of awareness and poor education,
patients are usually used to present late after having The prospective information on variables including age,
symptoms of acute MI.11 This complicates the management gender, history of diabetes, hypertension, hyperlipidemia,
and the results may not be the same as shown by the smoking, angiographic and procedural details (number of
western studies. Therefore, in addition to outcome we also vessels, segment of vessel, use of aspiration catheter, clot
evaluated the predictors of late ST resolution in this study. retrieval, use of stents, GP IIb IIIa inhibitors, Thrombolysis in
We believe that the local data is scarcely available in this Myocardial Infarction (TIMI) flow, and Tissue Myocardial
regard and our study not only adds on the available data but perfusion (TMP) grade and Electrocardiogram (ECG)
also provides the new piece of information regarding the findings were recorded.
above mentioned issue.
TIMI flow, TMP grades and ST resolution (on 12- lead ECG
The aim of our study was to compare the outcome of strips) were visually determined and documented by two
Primary PCI in patients presenting with early ST resolution independent observers before and after PCI and in case of
versus those presenting late ST resolution after the controversy third expert opinion was taken as final.
procedure.
Intracoronary thrombus was classified as: zero - No
thrombus, 1 - reduced contrast density / possible thrombus,
METHODOLOGY 2 - small size thrombus / greatest dimension ≤ ½ of vessel
This observational, prospective, single centre study was diameter, 3 - moderate size thrombus / greatest dimension
conducted at a tertiary care cardiovascular teaching > ½ and < 2 vessel diameter, 4 - large size thrombus / ≥ 2
hospital (National Institute of Cardiovascular Diseases, vessel diameter, 5 - total occlusion. 12
Karachi-Pakistan) from January 1st 2011 to October 31st
PCI success was defined as achievement of vessel patency
2012. All adult patients (≥ 18 years old) with chest pain
to a residual ≤ 30 %. Major bleeding was defined as a
lasting > 30 minutes and ST elevation of ≥ 1 mm in ≥ 2
hematoma ≥ 10 cm in diameter or bleeding requiring
contiguous leads were included in this study. In case of
transfusion, vascular surgery or resulting in major
posterior MI, ST depression of ≥ 2 mm in ≥ 2 precordial morbidity.
leads were also considered eligible for the study. Informed
consent was taken and detailed questionnaire was filled of TIMI flow grades were defined as: Zero - total occlusion
those patients who underwent primary PCI. resulting in no antegrade flow, 1 - minimal penetration of
contrast across the obstruction but fails to opacify the
Patients who received Thrombolytic therapy within 24 hours vessel, 2 - contrast opacifies the vessel beyond the

Pak Heart J 2015 Vol. 48 (01) : 42-47 43

 OUTCOME OF PRIMARY PCI WITH EARLY AND LATE ST RESOLUTION - EARLIER IS BETTER!

occlusion but with delay, 3 - normal complete perfusion of ST resolution was defined as any resolution or no resolution
entire vessel without any delay. 13 after 60 minutes of Primary PCI. Complete ST resolution
was defined as ≥ 70% ST resolution compared to baseline
TMP grades were defined as: Zero - minimal or no
ECG. No ST segment resolution was defined as persistent
myocardial blush, 1 - dye stains the myocardium and this
ST segment elevation or ≤ 30 % resolution of ST segment.15
stain persists on the next injection, 2 - dye enters the
myocardium but washes out slowly and strongly persists at Patients were followed in outpatient department (OPD) after
the end of injection, 3 - normal entrance and exit of dye in the one month, and at 1 year. Those patients who could not
myocardium.14 come in OPD, they were contacted through telephone and
follow up documented.
Early ST resolution was defined as ≥ 50% ST segment
resolution within 60 minutes of primary PCI, whereas, late All the data was entered and analyzed through SPSS
version17. Categorical variables like gender, diabetes,
Table 1: Baseline Demographic and Angiographic features hypertension, smoking, history of previous MI, cardiogenic
of Patients Underwent Primary PCI within 60 and shock, inotropic support, IABP, infarction territory, route of
after 60 Minutes of ST Resolution access etc were presented in frequencies and percentages.
ST Resolution ST Resolution Whereas continuous variables like age, height, weight, BMI,
Variables within 60 mins after 60 mins P-value symptom onset to ER and door to balloon time were
n=112 n=38 presented as mean ± SD. Chi square test was used for
Age in years [Mean ±SD] 50.4 +12.9 54.5 +8.1 0.023 significant association. Independent t-test for normally
Gender Male 103 (92%) 32 (84%) 0.169
distributed data and Mann Whitney U test were used for not
normally distributed data to compare mean (±SD) values of
Height in cm [Mean ±SD] 172.2 +7.1 170 +7.2 0.093
with and without aspiration of thrombus. P-value < 0.05
Weight in Kg [Mean ±SD] 77.8 +12.2 75.8 +8.4 0.281 was considered as statistically significant.
Diabetes 22 (19.6%) 15 (39.5%) 0.014
RESULTS
Hypertension 54 (48%) 16 (42%) 0.514

Smoking 46 (41%) 10 (26%) 0.104

Out of 150 patients enrolled, 112 (74.6 %) showed ST
resolution within 60 minutes. Table 1 is showing baseline
History of previous MI 22 (19.6%) 12 (31.6%) 0.129 demographic, clinical and angiographic features of both
Symptom onset to ER time 113.9 +137.5 141.4 +128.5 0.074 groups. Patients who showed ST resolution after 60 minutes
in minutes [Mean ±SD]*
were significantly elder than those revealed early ST
resolution. Diabetes, Multivessel disease and type C lesions
Door to Balloon time 101.6 +54.3 105.6 +72.0 0.586 were also more common in patients with late ST resolution
in minutes; [Mean ±SD]* (Table 1). Procedural characteristics were almost same in
≤ 90 minutes 55 (49%) 23 (60.5%) 0.223
both groups except the TIMI III flow that was significantly
more commonly seen in patients with early ST resolution
> 90 minutes 57 (51%) 15 (39.5%) (Table 2).
Infarction territory
Table 3 is showing the difference of outcomes of both
AWMI 76 (68%) 25 (66%) 0.814 groups underwent primary PCI. 100% immediate success
IWMI 36 (32%) 13 (34%) was achieved in patients showing early ST resolution, while
it was ~95% in patients with late ST resolution. At 30 days
Culprit Artery
and 1 year of follow up 103(90%) and 99(88.3%) were
LAD, Diagonal 72 (64.3%) 25 (65.8%) 0.875 stable, respectively, in patients with early ST resolution.
RCA 23 (20.5%) 10 (26.3%) 0.469 While only 19(50%) and 23(60.6 %) were stable in the other
group. Similarly, CABG and death were significantly more
LCx, Ramus 17 (15.2%) 03 (7.9%) 0.247
common in patients with late ST resolution (Table 3). Table 4
Lesion Risk is showing the comparison of group of patients with early
Type A, B 53 (47.3%) 10 (26.3%) 0.023 and late ST resolution whom DBT is ≤ 90 minutes.
Prolonged symptom onset to ER time (91.9±59.6 vs.
Type C 59 (52.7%) 28 (73.7%)
167.8±156.7 minutes; p=0.02) was significantly related to
Number of Diseased vessels late ST resolution.
SVD 70 (62.5%) 23 (60.5%) 0.816

2VD 22 (19.6%) 01 (2.6%) 0.012

DISCUSSION
3VD 20 (17.9%) 14 (36.9) 0.015 It is evident by our study that outcome of the patients

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 OUTCOME OF PRIMARY PCI WITH EARLY AND LATE ST RESOLUTION - EARLIER IS BETTER!

Table 2: Procedural Characteristics of the Groups of Patients STR group was worse than the early STR group. They were
Underwent Primary PCI Showing ST Resolution aged and majority of them having diabetes, multivessel
within 60 and After 60 Minutes disease and type C lesions. As a result this was not
surprising when they demonstrated a poor prognosis and
ST Resolution ST Resolution quite a few of them showed a suboptimal TIMI flow grades
Variables within 60 mins after 60 mins P-value immediately after PCI (Table 2). It is a well known fact that
n=112 n=38
aged population has got worse atherosclerotic
Grade of stenosis cardiovascular disease. They have poor microvasculature,
Total (100 %) 66 (59%) 26 (68.4%) 0.298 and badly diseased endothelium that may not be responded
well even following the restoration of coronary blood flow
Sub-total (91-99%) 11 (10%) 04 (10.5%) 0.900
after the primary PCI.16, 17 Similarly, diabetes badly damages
Severe (70-90%) 35 (31%) 08 (21.1%) 0.229 the vascular system in general and microvasculature in
Lesion length particular. Therefore, even after the restoration of coronary
vessel myocardium may not be well perfused due to
≤ 20 mm 71 (63.4%) 22 (58%) 0.546 diseased microvasculature and hence, late STR ensued.18
> 20 mm 41 (36.6%) 16 (42%) Recent studies have shown the increased risk of major
Size of culprit artery adverse cardiovascular events after primary PCI in case of
multivessel disease if the other vessels are not
≤ 3 mm 36 (32%) 10 (26.3%) 0.501
intervened.19,20 Therefore recently published landmark
> 3 mm 73 (68%) 28 (73.7%) Complete versus Lesion-only Primary PCI Trial (CvLPRIT)
Clot retrieved 38 (34%) 14 (37%) 0.752 study have shown a 55% reduction in major adverse
cardiovascular events in those patients presenting for
Adenosine used 23 (20.5%) 09 (23.7%) 0.682 primary percutaneous coronary interventions when the non-
Size of stent deployed
Table 3: Outcomes of the Patients Underwent
≤ 20 mm 49 (43.7%) 13 (34.2%) 0.303
Primary PCI within 60 and After
> 20 mm 48 (42.9%) 16 (42.1%) 0.939 60 Minutes of ST Resolution
> one stent 09 (8%) 07 (18.4%) 0.079 ST Resolution ST Resolution
06 (5.4%) 02 (5.3%) 0.999
Variables within 60 mins after 60 mins P-value
stenting not done n=112 n=38
TIMI flow Immediate after Procedure

Zero – I 0 01 (2.6%) 0.125 Successful PCI 112 (100%) 36 (94.7%) 0.014

II 03 (2.7%) 04 (10.5%) 0.051 Major bleeding 0 01 (2.6%) 0.125
III 109 (97.3%) 33 (86.9%) 0.012 Death 0 01 (2.6%) 0.125
TMP Grade Follow up after 30 days

Zero – I 67 (59.8%) 25 (65.8%) 0.514 Stable 103 (92%) 19 (50%) < 0.001
II & III 45 (40.2%) 13 (34.2%) 0.514 CABG 02 (1.7%) 06 (15.8%) 0.001

showing late or no STR after primary PCI is dismal. This MACE 03 (2.7%) 01 (2.6%) 0.999
group did not show stable follow up and encountered more Death 01 (0.9%) 03 (7.9%) 0.019
frequent adverse cardiac events like CABG and death. This
Lost follow up 03 (2.7%) 09 (23.7%) < 0.001
finding is consistent with previous studies in which the same
issue of STR was addressed. It was previously reported that Follow up after 1 year
patients with early STR had more preserved LVEF and Stable 99 (88.3%) 23 (60.6%) < 0.001
smaller infarct size compared to patients with late or no
STR.9 Therefore it is understandable if the patients with late CABG 03 (2.7%) 06 (15.8%) 0.004
STR showed poor outcome results in our study. MACE 05 (4.5%) 01 (2.6%) 0.630
Within 60 minutes of time window three fourths (74.7%) of Death 04 (3.6%) 04 (10.5%) 0.093
our patients showed satisfactory STR. While 28 (18.7%)
Lost follow up 01 (0.9%) 04 (10.5%) 0.005
patients showed STR after 60 minutes and 10 (6.7%)
patients did not show any resolution. The risk profile of late PCI=Percutaneous coronary intervention; CABG=Coronary artery bypass grafting;
MACE=Major adverse cardiovascular events

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 OUTCOME OF PRIMARY PCI WITH EARLY AND LATE ST RESOLUTION - EARLIER IS BETTER!

Table 4: Comparison Between ST Resolution between the government and health care authorities.
within & after 60 Mins Who's Door to
Balloon Time < 90 mins CONCLUSION
Outcome of patients showing early ST resolution is
ST Resolution ST Resolution significantly better than those showing late ST resolution.
Variables within 60 mins after 60 mins P-value Elderly age, diabetes, longer chest pain to ER time and
n=55 n=23
diffuse three vessel disease are associated with late ST
Age in years [Mean ±SD] 50.1 ± 12.6 53.6 ± 8.8 0.165
resolution. Outcome of late presenter (patients who have
Gender Male 49 (89%) 20 (87%) 0.999 longer chest pain to ER time) remains poor even after
achieving standard DBT of 90 minutes.
Height in cm [Mean ±SD] 172.1 ± 7.3 168.8 ± 7.3 0.072

Weight in Kg [Mean ±SD] 78.3 ± 14.7 75.5 ± 8.9 0.309

ACKNOWLEDGMENT

Diabetes 11 (20%) 08 (35%) 0.165 Authors wish to thanks Mr. Jaffer Bin Baqar for his help in
data management and analysis.
Hypertension 26 (47%) 10 (43.5%) 0.759

Smoking 23 (42%) 05 (22%) 0.092 REFERENCES

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