1. 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 Although 90-minute TIMI flow grades (TFGs), corrected TIMI frame counts (CTFCs), and TIMI myocardial perfusion grades (TMPGs) have been associated with 30-day outcomes, we hypothesized that these indices would be related to long-term outcomes after thrombolytic administration. We also hypothesized that in the modern era of interventional cardiology, that rescue and adjunctive PCI would be associated with improved long-term outcomes. We also hypothesized that measures of flow before PCI would be associated with long-term outcomes Although 90-minute TIMI flow grades (TFGs), corrected TIMI frame counts (CTFCs), and TIMI myocardial perfusion grades (TMPGs) have been associated with 30-day outcomes, we hypothesized that these indices would be related to long-term outcomes after thrombolytic administration. We also hypothesized that in the modern era of interventional cardiology, that rescue and adjunctive PCI would be associated with improved long-term outcomes. We also hypothesized that measures of flow before PCI would be associated with long-term outcomes Gibson et al, Circulation 2002, 105:1909-1913

2. 90 Minute Pre PCI TIMI Flow Grade (TFG) is Associated with 2 Year Survival Following Thrombolytic Administration Gibson et al, Circulation 2002, 105:1909-1913 Years 3- way log-rank p=0.0013 Survival TFG 0/1 TFG 2 TFG 3 In a MV model correcting for previously identified correlates of mortality (age, sex, pulse, left anterior descending artery infarction and any PCI during the index hospitalization), pre PCI patency (TFG 2/3)(HR0.32, p<0.001, pre PCI CTFC (p=0.01) and pre PCI TMPG 2/3 (HR 0.46, p=0.02) all remained independently associated with reduced 2 year mortality

3. Pre-PCI 90 Minute TMPG is Associated with 2 Year Survival Following Fibrinolytic Administration Gibson et al, Circulation 2002, 105:1909-1913 Log rank p=0.03 Years Survival TMPG 2/3 TMPG 0/1 Even after adjusting for the performance of adjunctive / rescue PCI, a closed myocardium before PCI was associated with poorer survival by 2 yrs

4. 2 Year Survival Following Rescue PCI in Patients with a Closed Artery Following Thrombolytic Administration Gibson et al, Circulation 2002, 105:1909-1913 Log rank p=0.03 Survival was Improved in patients with 90 minute TIMI Grade 0/1 Flow who underwent rescue PCI Years Survival Rescue PCI No Rescue PCI

5. 2 Year Survival Associated with Adjunctive PCI in Patients with an Open Artery Following Thrombolytic Administration Gibson et al, Circulation 2002, 105:1909-1913 Survival tended to be improved in patients with an open artery at 90 minutes who underwent immediate adjunctive or delayed PCI Years p=0.11; after adjusting for stent use p=0.07 for adjunctive PCI Immediate Adjunctive PCI Delayed PCI No PCI

6. ConclusionsConclusions Both improved epicardial flow (TFG 2/3 and low CTFCs) and tissue-level perfusion (TMPG 2/3) at 90 minutes after thrombolytic administration are independently associated with improved 2-year survival, suggesting complementary mechanisms of improved long-term survival. Although rescue PCI was associated with reduced long- term mortality, improved microvascular perfusion (TMPG 2/3) before PCI was also related to improved mortality independently of epicardial blood flow and the performance of rescue or adjunctive PCI. Further prospective trials are warranted to re-examine the benefit of early PCI with thrombolysis. Both improved epicardial flow (TFG 2/3 and low CTFCs) and tissue-level perfusion (TMPG 2/3) at 90 minutes after thrombolytic administration are independently associated with improved 2-year survival, suggesting complementary mechanisms of improved long-term survival. Although rescue PCI was associated with reduced long- term mortality, improved microvascular perfusion (TMPG 2/3) before PCI was also related to improved mortality independently of epicardial blood flow and the performance of rescue or adjunctive PCI. Further prospective trials are warranted to re-examine the benefit of early PCI with thrombolysis. Gibson et al, Circulation 2002, 105:1909-1913