TIMI flow grade: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
Line 11: Line 11:
==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>  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 TFGs with mortality must be interpreted with caution as there are several confounders:
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 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]]).<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>  
*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>  


*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.
*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 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>
*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.<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 [[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).<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 15:29, 3 May 2014

Coronary Angiography

Home

General Principles

Overview
Historical Perspective
Contraindications
Appropriate Use Criteria for Revascularization
Complications
Technique
Film Quality

Anatomy & Projection Angles

Normal Anatomy

Coronary arteries
Dominance
Right System
Left System
Left Main
Left Anterior Descending
Circumflex
Median Ramus

Anatomic Variants

Separate Ostia
Anomalous Origins
Case Example
Fistula

Projection Angles

Standard Views
Left Coronary Artery
Right Coronary Artery

Epicardial Flow & Myocardial Perfusion

Epicardial Flow

TIMI Frame Count
TIMI Flow Grade
TIMI Grade 0 Flow
TIMI Grade 1 Flow
TIMI Grade 2 Flow
TIMI Grade 3 Flow
TIMI Grade 4 Flow
Pulsatile Flow
Deceleration

Myocardial Perfusion

TIMI Myocardial Perfusion Grade
TMP Grade 0
TMP Grade 0.5
TMP Grade 1
TMP Grade 2
TMP Grade 3

Lesion Complexity

ACC/AHA Lesion-Specific Classification of the Primary Target Stenosis

Preprocedural Lesion Morphology

Eccentricity
Irregularity
Ulceration
Intimal Flap
Aneurysm
Sawtooth Pattern
Length
Ostial location
Angulation
Proximal tortuosity
Degenerated SVG
Calcification
Total occlusion
Coronary Artery Thrombus
TIMI Thrombus Grade
TIMI Thrombus Grade 0
TIMI Thrombus Grade 1
TIMI Thrombus Grade 2
TIMI Thrombus Grade 3
TIMI Thrombus Grade 4
TIMI Thrombus Grade 5
TIMI Thrombus Grade 6

Lesion Morphology

Quantitative Coronary Angiography
Definitions of Preprocedural Lesion Morphology
Irregular Lesion
Disease Extent
Arterial Foreshortening
Infarct Related Artery
Restenosis
Degenerated SVG
Collaterals
Aneurysm
Bifurcation
Trifurcation
Ulceration

Left ventriculography

Technique
Quantification of LV Function
Quantification of Mitral Regurgitation

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.

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 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


Occlusion Penetration Slow flow Normal flow
Retrieved from "https://www.wikidoc.org/index.php?title=TIMI_flow_grade&oldid=968271"