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Accuracy of Post-thrombolysis ST-segment Reduction as an Adequate Reperfusion Predictor in the Pharmaco-Invasive
Henrique Tria Bianco1, Rui Povoa2, Maria Cristina Izar2
1Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, SP - Brasil.
Insights
Electrocardiogram (ECG) ST-segment reduction after fibrinolysis is not a reliable indicator of successful coronary reperfusion. Angiography is recommended to confirm adequate blood flow, even with apparent ECG improvement in ST-Segment Elevation Myocardial Infarction (STEMI) patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Emergency Medicine
Background:
- Primary percutaneous coronary intervention is the standard for coronary reperfusion.
- Drug-invasive strategies using fibrinolysis are alternatives when PCI is unavailable.
- Electrocardiogram (ECG) monitoring is used to assess reperfusion success.
Purpose of the Study:
- To evaluate ST-segment changes on ECG after thrombolysis as a predictor of coronary recanalization.
- To compare ECG findings with angiographic outcomes using TIMI-flow and Myocardial Blush Grade (MBG) as criteria for ideal reperfusion.
Main Methods:
- Studied 2,215 ST-Segment Elevation Myocardial Infarction (STEMI) patients treated with Tenecteplase (TNK) fibrinolysis.
- ECGs were recorded before and 60 minutes after TNK administration.
- Patients were classified based on angiographic reperfusion (TIMI-3/MBG-3) versus inadequate reperfusion (TIMI/MBG <3).
- ECG reperfusion was defined as ST-segment reduction >50%.
Main Results:
- The ECG reperfusion criterion demonstrated a sensitivity of 79% and specificity of 40%.
- Positive predictive value was 56%, and negative predictive value was 66%.
- A weak positive correlation (r=0.21) was found between ST-segment reduction and ideal angiographic reperfusion, with low diagnostic accuracy (AUC=0.60).
Conclusions:
- ST-segment reduction on ECG is insufficient for accurately identifying adequate angiographic reperfusion.
- Angiography is crucial for confirming both macro- and microvascular coronary flow, even with seemingly successful reperfusion on ECG.
Background:
Primary percutaneous coronary intervention is considered the "gold standard" for coronary reperfusion. However, when not available, the drug-invasive strategy is an alternative method and the electrocardiogram (ECG) has been used to identify reperfusion success.
Objectives:
Our study aimed to assess ST-Segment changes in post-thrombolysis and their power to predict recanalization and using the angiographic scores TIMI-flow and Myocardial Blush Grade (MBG) as an ideal reperfusion criterion.
Methods:
2,215 patients with ST-Segment Elevation Myocardial Infarction (STEMI) undergoing fibrinolysis [(Tenecteplase)-TNK] and referred to coronary angiography within 24 h post-fibrinolysis or immediately referred to rescue therapy were studied. The ECG was performed pre- and 60 min-post-TNK. The patients were categorized into 2 groups: those with ideal reperfusion (TIMI-3 and MBG-3) and those with inadequate reperfusion (TIMI and MBG <3). The ECG reperfusion criterion was defined by the reduction of the ST-Segment >50%. A p-value <0.05 was considered for the analyses, with bicaudal tests.
Results:
The ECG reperfusion criterion showed a positive predictive value of 56%; negative predictive value of 66%; sensitivity of 79%; and specificity of 40%. There was a weak positive correlation between ST-Segment reduction and ideal reperfusion angiographic data (r = 0.21; p <0.001) and low diagnostic accuracy, with an AUC of 0.60 (95%CI: 0.57-0.62).
Conclusion:
The ST-Segment reduction was not able to accurately identify patients with adequate angiographic reperfusion. Therefore, even patients with apparently successful reperfusion should be referred to angiography soon, to ensure adequate macro and microvascular coronary flow.
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