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The aim of this study was to describe the time course of NT pro-B-type natriuretic peptide (NT pro-BNP) levels in patients with large anterior ST-segment elevation myocardial infarction (STEMI) treated with primary angioplasty (PPCI) and to investigate the relationship between these values and both microvascular reperfusion and left ventricular (LV) function.The clinical efficacy of PPCI is largely dependent on the achievement of microvascular reperfusion. Myocardial blush is an angiographic method to evaluate the presence of effective reperfusion after PPCI. NT pro-BNP is a biomarker of LV stress whose levels are also related to clinical outcome in STEMI.We studied 84 patients with large anterior STEMI treated with PPCI. NT pro-BNP was measured at baseline, after 2 days (day 2) and 7 days (day 7). Echocardiographic LV ejection fraction (LVEF) was measured at baseline, day 7 and after 6 months. Myocardial blush was graded immediately after PPCI.NT pro-BNP increased from admission to day 2 and decreased from day 2 to day 7 in patients with significant myocardial blush (grade 2–3) as well as in patients with 0–1 myocardial blush. However, in the latter group median NT pro-BNP levels globally increased from admission to day 7, whereas they decreased in patients with significant myocardial blush. Moreover, in such patients LVEF was higher at all time points than in patients with a grade 0–1 myocardial blush.This study shows that the time course of NT pro-BNP in the first week after an anterior STEMI is dependent on the effectiveness of microvascular reperfusion assessed after PPCI and reflects the evolution of LVEF over time.