TIMI flow grade

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Hilda Mahmoudi M.D., M.P.H.[2]

Synonyms and keywords: TIMI flow, TIMI flow grade, TFG

Overview

The TIMI flow grading system is a widely used method of grading coronary flow.[1] While the TMPG that was invented by C. Michael Gibson M.S., M.D. assesses perfusion in the capillary bed at the tissue level,[2] the TIMI flow grade is used to assess epicardial coronary blood flow.

Clinical Importance and Evaluation

The Thrombolysis In Myocardial Infarction (TIMI) flow grade classification scheme has been widely used to assess coronary blood flow in acute coronary syndromes.[3] The association of the TIMI Flow Grades (TFG)s with clinical outcomes including mortality has been well documented,[4] [5] [6] [7] [8] [9] [10] although the association of the TFGs with mortality must be interpreted with caution as there are several confounders:

  • The majority of TIMI grade 2 flow is observed in the left anterior descending artery (LAD) territory, whereas the majority of TIMI grade 3 flow is observed in the right coronary artery (RCA).[9] Thus, the improved mortality observed among patients with TIMI grade 3 flow may be explained at least in part by the fact that inferior myocardial infarction (MI) location is associated with a lower mortality rate. [9]
  • The clinical improvement associated with TIMI grade 3 flow may have be nonlinear. For example, greater clinical benefits may be observed if a closed artery (TFG 0/1) is opened with even slow flow (TIMI grade 2 flow) compared with the improvement that might occur if an artery with TIMI grade 2 flow is converted to TIMI grade 3 flow.
  • As more arteries with TIMI grade 2 flow are treated with adjunctive percutaneous coronary intervention (PCI), the prognosis associated with this flow grade may improve. The fact that patients who were treated with an inferior fibrinolytic monotherapy strategy faired so well in GUSTO V may be explained in part by the fact that these patients underwent PCI more often.[11] [12] Two-year follow-up in more recent studies indicates that the survival advantage of TIMI grade 3 flow over TIMI grade 2 flow at 2 years may not be as great as it once was in the era before aggressive utilization of rescue and adjunctive (PCI).[13]

TIMI Flow Grade (TFG)

TIMI Flow Grade 0

No perfusion. No antegrade flow beyond the point of occlusion. [14] [10] [13]

Examples

Click here for an example of TIMI Flow Grade 0.

TIMI Flow Grade 1

Penetration without perfusion. Contrast material passes beyond the area of obstruction but fails to opacify the entire coronary bed distal to the obstruction for the duration of the cineangiographic filming sequence.[14] [10] [13]

This category is subdivided into:

  • 1.0: dye minimally leaks past the area of obstruction.
  • 1.5: dye leaks well past the area of obstruction but fails to opacify the entire coronary bed.

Examples

Click here for an example of TIMI Flow Grade 1.

TIMI Flow Grade 2

Partial perfusion. Contrast material passes across the obstruction and opacifies the coronary bed distal to the obstruction. However, the rate of entry of contrast material into the vessel distal to the obstruction or its rate of clearance from the distal bed (or both) are perceptibly slower than its flow into or clearance from comparable areas not perfused by the previously occluded vessel (i.e. opposite coronary artery or the coronary bed proximal to the obstruction).[14] [10] [13]

This category is subdivided into:

  • 2.0: TIMI 2 slow flow, dye markedly delayed in opacifying distal vasculature.
  • 2.5: TIMI 2 fast flow, dye minimally delayed in opacifying distal vasculature.

Examples

Click here for an example of TIMI Flow Grade 2.

TIMI Flow Grade 3

Complete perfusion. Antegrade flow into the bed distal to the obstruction occurs as promptly as antegrade flow into the bed proximal to 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.[14] [10] [13]

Examples

Click here for an example of TIMI Flow Grade 3.

TIMI Flow Grade 4

TIMI grade 4 flow is a term developed by Dr. C. Michael Gibson, M.S., M.D. to describe hyperemic flow on a coronary arteriogram.[15] Hyperemic flow on a coronary arteriogram is defined qualitatitively as near instantaneous filling of the coronary artery with dye, and quantitatively as a corrected TIMI frame count < 14 frames. Hyperemic flow in a coronary artery may be due to either repayment of oxygen debt following ischemia due to a balloon inflation for instance, or distal embolization. If it is due to distal embolization, and if impaired myocardial perfusion is present (TIMI myocardial perfusion grade 0 or TIMI myocardial perfusion grade 1), then the mortality associated with TIMI grade 4 flow is actually higher than that of TIMI grade 3 flow.[15] In this scenario, the hyperemic flow is a surrogate or marker of endogenous adenosine release due to distal embolization, rather than being causally related to adverse outcomes.

The TIMI Frame Count

The TIMI flow grade, while useful, has been largely supplanted by the more quantitative measure named TIMI frame count, which is the number of frames required for dye to traverse the length of the artery. The TIMI frame count provides prognostic information independent of the TIMI Flow Grade. For more detailed information about TIMI frame count (TFC) click here.

References

  1. The Thrombolysis in Myocardial Infarction (TIMI... [N Engl J Med. 1985 - PubMed - NCBI]. Retrieved on 29 August 2013.
  2. Gibson CM, Cannon CP, Murphy SA, Ryan KA, Mesley R, Marble SJ et al. (2000). "Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs.". Circulation 101 (2): 125-30. PMID 10637197.
  3. The TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. N Engl J Med. 1985; 312: 932–936.
  4. Simes RJ, Topol EJ, Holmes DR, et al. Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion: importance of early and complete infarct artery reperfusion. Circulation. 1995; 91: 1923–1928.
  5. The GUSTO Angiographic Investigators. The effects of tissue plasminogen activator, streptokinase, or both on coronary artery patency, ventricular function, and survival after acute myocardial infarction. N Engl J Med. 1993; 329: 1615–1622.
  6. Vogt A, Von Essen R, Tebbe U, et al. Impact of early perfusion status of the infarct-related artery on short-term mortality after thrombolysis for acute myocardial infarction: retrospective analysis of four German multicenter studies. J Am Coll Cardiol. 1993; 21: 1391–1395.
  7. Karagounis L, Sorensen SG, Menlove RI, et al. Does thrombolysis in myocardial infarction TIMI perfusion grade 2 represent a mostly patent artery or a mostly occluded artery? Enzymatic and electrocardiographic evidence from the TEAM-2 study. J Am Coll Cardiol. 1992; 17: 1–10.
  8. Anderson JL, Karagounis LA, Becker LC, et al. TIMI perfusion grade 3 but not grade 2 results in improved outcome after thrombolysis for myocardial infarction: ventriculographic, enzymatic, and electrocardiographic evidence from the TEAM-3 study. Circulation. 1993; 87: 1829–1839.
  9. 9.0 9.1 9.2 Gibson CM, Cannon CP, Daley WL, et al. The TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation. 1996; 93: 879–888.
  10. 10.0 10.1 10.2 10.3 10.4 Gibson CM, Murphy SA, Rizzo MJ, et al. The relationship between the TIMI frame count and clinical outcomes after thrombolytic administration. Circulation. 1999; 99: 1945–1950.
  11. The GUSTO V Investigators. Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition: the GUSTO V randomised trial. Lancet. 2001; 357: 1905–1914.
  12. Hudson MP, Granger CB, Topol EJ, et al. Early reinfarction after fibrinolysis: experience from the global utilization of streptokinase and tissue plasminogen activator (alteplase) for occluded coronary arteries (GUSTO I) and global use of strategies to open occluded coronary arteries (GUSTO III) trials. Circulation. 2001; 104: 1229–1235.
  13. 13.0 13.1 13.2 13.3 13.4 Gibson CM, Cannon CP, Murphy SA, et al. Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction. Circulation. 2002; 105: 1909–1913.
  14. 14.0 14.1 14.2 14.3 Gibson, CM; Ryan, K; Sparano, A; Rizzo, M; Moynihan, J; Kelley, M; Marble, SJ; Dodge, JT; Antman, EM. Methodologic drift in the assessment of TIMI grade 3 flow and its implications with respect to the reporting of angiographic trial results. Am Heart J. 1999;137:1179–1184. PMID 10347349
  15. 15.0 15.1 Gibson CM, Pride YB, Buros JL, Kunadian V, Southard MC, Harrigan CJ et al. (2008). "Relation of hyperemic epicardial flow to outcomes among patients with ST-segment elevation myocardial infarction receiving fibrinolytic therapy.". Am J Cardiol 101 (9): 1232-8. doi:10.1016/j.amjcard.2007.12.023. PMID 18435949.


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Occlusion Penetration Slow flow Normal flow

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