Early noninvasive detection of failed epicardial reperfusion after fibrinolytic therapy

Available noninvasive techniques for identifying patients with failed epica rdial reperfusion after fibrinolytic therapy are limited by poor accuracy. It is unknown whether combining multiple noninvasive predictors would impro ve diagnostic accuracy and facilitate identification of candidates for resc ue percutaneous coronary intervention. In the Thrombolysis In Myocardial In farction (TIMI) 14 trial, we evaluated the ability of ST-segment resolution (n = 606), chest pain resolution (n = 859), and the ratio of 60-minute/bas eline serum myoglobin (n = 308) to identify patients with angiographic evid ence of failed reperfusion 90 minutes after fibrinolysis. Three criteria we re prospectively defined: < 50% ST resolution at 90 minutes, presence of ch est pain at the time of angiography, and myoglobin ratio < 4. Patients who met any individual criterion were more likely to have less than TIMI 3 flow and an occluded infarct-related artery (TIMI 0/1 flow) than those who did not meet the criterion (p < 0.005 for each). When the 3 criteria were used together (n = 169), patients who satisfied 0 (n = 29), 1 (n = 68), 2 (n = 5 1), or 3 (n = 21) of the criteria had a 17%, 24%, 35%, and 76% probability of failing to achieve TIMI 3 flow (p < 0.0001 for trend), a 0%, 6%, 18%, an d 57% probability of an occluded infarct-related artery (p < 0.0001 for tre nd), and a 0%, 1.5%, 2.0%, and 9.5% rate of 30-day mortality (p = 0.05 for trend), respectively. Use of the criteria in combination increased positive predictive values without decreasing negative predictive values. In conclu sion, ST-segment resolution, chest pain resolution, and early washout of se rum myoglobin can be used in combination to aid in the early noninvasive id entification of candidates for rescue percutaneous coronary intervention. ( C) 2001 by Excerpta Medica, Inc.