ORIGINAL ARTICLE Myocardial blush grade: a predictor for major adverse cardiac events after primary PTCA with stent implantation for acute myocardial infarction Mehmet G. KAYA 1 , Fatih ARSLAN 2 , Adnan ABACI 1 , Geert van der HEIJDEN 3 , Timur TIMURKAY- NAK 1 , Atiye CENGEL 1 1 Department of Cardiology at the Gazi University Medical School, Ankara, Turkey; 2 Heart Lung Center Utrecht, Department of Cardiology Medical Center Utrecht, 3 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands. Objectives — Optimal myocardial reperfusion is of great importance for survival of patients with AMI undergoing PTCA. According to the Thrombolysis In Myocardial Infarction (TIMI) 3∞∞score, restoration of epicardial flow is achieved in the majority of patients. However, the myocardial blush grade (MBG) may offer additional information for survival. Therefore, we sought to determine whether myocardial blush grades were associated with MACE during follow-up in a high-risk AMI population undergoing primary PTCA with stent implantation. Methods — Hundred-and-thirty patients with AMI underwent PTCA with stent implantation from 1999 to 2004.The clinical, angiographic and follow-up data were extracted from the hospital records. Apart from the availability and technical adequacy of the angiograms for angiographic analysis, there were no exclusion criteria. Results — Post procedural TIMI 3 flow was achieved in 103 (79%) patients, while MBG-3 was observed in only 44 (34%) patients. Less post-intervention AMI, cardiac deaths or any MACE occurred in patients with MBG 3 (4/44) compared with MBG 1 or 2 (36/86) (P<∞∞0.01). MBG 3 was a strong predictor of absence of MACE during 5-year follow-up (P<∞∞0.01), whereas no association was found between TIMI 3 and event-free survival (P>∞∞0.5) in our population. Conclusion — Our data show that (1) MBG 3 is an important marker for survival and (2) the pre- dictive value of MBG is superior to the TIMI flow grades. Given the predictive validity of MBG shown for MACE-free survival and low rate of MBG 3 despite achievement of TIMI 3 flow, a prospective study with adjunctive therapies to enhance myocardial perfusion is warranted. Keywords: myocardial blush grade – myocardial infarction – reperfusion. Introduction Despite efforts to improve the outcome of patients with acute myocardial infarction (AMI) 1-2 , and high rate of flow restoration (Thrombolysis In Myocardial Infarction [TIMI]–3 flow) in∞∞>∞∞90% of patients with acute myocardial infarction (AMI) undergoing percu- taneous transluminal coronary angioplasty (PTCA) 3- 4 , myocardial recovery is often less optimal and survival is difficult to predict for the individual patient 5 . Like in studies with myocardial contrast echocar- diography 6 , single-photon emission computed tomog- raphy imaging 7 , and nuclear scintigraphy imaging 8 , it has clearly been documented that myocardial perfu- sion is often reduced despite restoration of TIMI 3 flow in the infarct-related artery, and may result in per- sistent ST-segment elevation and poor clinical out- come 5,9-13 . As the major objective in the treatment of AMI has become the complete and sustained reperfu- sion of myocardial tissue in addition to the restora- tion of TIMI 3 blood flow in the coronary artery 14 , the need for a simple, reliable and reproducible index for the evaluation of microvascular function increased. In 1998 van `t Hof et al. 11 introduced the concept of myocardial blush grade (MBG) for the direct assess- ment of myocardial reperfusion in patients with restored patency of the infarct-related artery. MBG is Address for correspondence: Fatih Arslan, M.D., University Medical Center Utrecht, Department of Cardiology, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. E-mail: f.arslan@umcutrecht.nl Received 13 February 2007; accepted for publication 27 July 2007. Acta Cardiol 2007; 62(2): 000-000 doi: ??? 1