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==Clinical Importance and Evaluation==
==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.<ref name="TIMI1"> The TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. N Engl J Med. 1985; 312: 932–936.</ref> TFG 0 means the artery is closed; TFG 1 means that dye penetrates the stenosis but does not reach the downstream bed; TFG 2 means that flow is slow down the artery and TFG 3 means that normal flow has been restored. The association of the TFGs with clinical outcomes (including mortality) has been well documented <ref name="Simes">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.</ref> <ref name="Gusto">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.</ref> <ref name="Vogt1"> 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. </ref> <ref name="Karagounis"> 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. </ref> <ref name="anderson3"> 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. </ref> <ref name="Gibson 1"> 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.</ref> <ref name="Gibson2">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. </ref>
The Thrombolysis In Myocardial Infarction (TIMI) flow grade classification scheme has been widely used to assess coronary blood flow in acute coronary syndromes.<ref name="TIMI1"> The TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) trial. Phase I findings. N Engl J Med. 1985; 312: 932–936.</ref> The association of the TIMI Flow Grades (TFG)s with clinical outcomes including mortality has been well documented <ref name="Simes">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.</ref> <ref name="Gusto">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.</ref> <ref name="Vogt1"> 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. </ref> <ref name="Karagounis"> 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. </ref> <ref name="anderson3"> 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. </ref> <ref name="Gibson 1"> 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.</ref> <ref name="Gibson2">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. </ref> Although the association of the [[TIMI Flow Grade (TFG)|TFGs]] with mortality must be interpreted with caution as there are several confounders. First, 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)<ref name="Gibson 1">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.</ref>. 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; <ref name="Gibson 1">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.</ref> Second,  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 (TFG 2) compared with the improvement that might occur if an artery with TFG 2 is converted to [[TIMI Flow Grade (TFG)|TFG]] 3 flow; And third, as more arteries with TFG 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 <ref>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. </ref> <ref name="Hudson1">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. </ref>. Two-year follow-up in more recent studies indicates that the survival advantage of TFG 3 flow over TFG 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) <ref name="Gibson3"> 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. </ref>
 
The association of the [[TIMI Flow Grade (TFG)|TFGs]] with mortality must be interpreted with caution as there are several confounders:
 
1. 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)<ref name="Gibson 1">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.</ref>. 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 <ref name="Gibson 1">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.</ref>  
 
2. 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 (TFG 2) compared with the improvement that might occur if an artery with TFG 2 is converted to [[TIMI Flow Grade (TFG)|TFG]] 3 flow.
 
3. As more arteries with TFG 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 <ref>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. </ref> <ref name="Hudson1">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. </ref>. Two-year follow-up in more recent studies indicates that the survival advantage of TFG 3 flow over TFG 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) <ref name="Gibson3"> 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. </ref>


==TIMI Flow Grade (TFG)==
==TIMI Flow Grade (TFG)==

Revision as of 17:45, 29 August 2013

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

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. First, 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] Second, 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 (TFG 2) compared with the improvement that might occur if an artery with TFG 2 is converted to TFG 3 flow; And third, as more arteries with TFG 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 TFG 3 flow over TFG 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)

Grade 0

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

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.


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.

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]

=

The TIMI Frame Count

The TIMI flow grade, while useful, has been largely supplanted by the more quantitative measure of the more quantitative 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.

Occlusion Penetration Slow flow Normal flow

References

  1. ↑ "The Thrombolysis in Myocardial Infarction (TIMI... [N Engl J Med. 1985] - PubMed - NCBI". Retrieved 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
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