# TIMI flow — Original TIMI epicardial coronary flow grade

> Per-vessel, per-timepoint qualitative grade of epicardial coronary contrast entry, distal-bed opacification and clearance on invasive angiography. It is not the TIMI ACS risk score, TIMI myocardial perfusion grade, myocardial blush grade, corrected TIMI frame count or cerebral mTICI, and it cannot diagnose the mechanism, quantify tissue perfusion, select therapy or predict an individual's outcome by itself.

**Situação:** vigente · **Órgão:** Cardíaco · **Órgão emissor:** TIMI Study Group · **Versão:** 1985 original; 1996 corrected frame-count companion; 1999 three-cycle drift guard; 2025 ACS care boundary · **Ano:** 1985

> ⚠️ Uma versão mais nova pode existir (em revisão).

## Procedência e vigência
- Família: léxico
- Tipo de lógica: flat
- Modalidade: Angiography
- Fonte primária: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437
- Última verificação: 2026-07-24
- Última checagem: 2026-08-12

## Lógica de decisão
Always bind the grade to artery and timepoint. It describes epicardial contrast flow only; mechanism, tissue perfusion, clinical risk and management are separate outputs.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0, no perfusion | Original TIMI grade 0, no perfusion: no antegrade contrast flow is seen beyond the point of epicardial coronary occlusion in the named artery at the stated angiographic timepoint. Collateral filling is recorded separately and does not convert absent antegrade culprit flow into a higher grade. | Treat this as an urgent angiographic observation in its ACS or procedural context and determine whether the cause is acute thrombotic occlusion, chronic occlusion, dissection, spasm, embolus, another mechanical lesion or technical injection failure. The numeral alone cannot select wire crossing, thrombectomy, stenting, medication, surgery or futility. | Absent antegrade flow has been associated with worse group outcomes in historical reperfusion cohorts, especially when persistent after treatment, but grade, artery, pre/post-intervention timepoint, shock, infarct burden and tissue perfusion must be integrated. Do not attach an old cohort mortality percentage to an individual. | TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 0; Rao et al. 2025 ACS guideline, DOI 10.1016/j.jacc.2024.11.009, syndrome/revascularization context; Gibson et al. 1996, DOI 10.1161/01.CIR.93.5.879, qualitative versus quantitative flow boundary. | ✓ |
| 1 | Grade 1, penetration without perfusion | Original TIMI grade 1, penetration without perfusion: contrast passes beyond the obstruction but hangs up and fails to opacify the entire distal coronary bed during the cine run. Complete distal-bed filling is the decisive grade-1 versus grade-2 boundary. | Assess the persistent obstruction and procedural context, injection adequacy, thrombus, dissection, spasm, distal embolization and collaterals. Grade 1 signals ineffective antegrade distal perfusion but does not itself prescribe another device pass, a drug or an endpoint decision. | Grade 1 represents severely impaired epicardial flow and historically clusters with poor reperfusion, but it is not a calibrated personal prognosis and must not be pooled with grade 0 unless a cited study prespecified that analysis. | TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original penetration-without-perfusion definition; Gibson et al. 1999, PMID 10347349, preservation of original definitions; 2025 ACC/AHA multisociety ACS guideline for current care context. | ✓ |
| 2 | Grade 2, partial perfusion | Original TIMI grade 2, partial perfusion: contrast passes the obstruction and opacifies the entire distal coronary bed, but either distal entry or clearance is perceptibly slower than flow proximal to the obstruction or in a comparable uninvolved bed. A patent-looking vessel is not grade 3 unless both entry and washout are normal-reference prompt. | Investigate residual epicardial obstruction, thrombus, dissection, spasm, distal embolization, microvascular no-reflow, hemodynamics and technical factors. Post-PCI grade 2 can mark suboptimal flow, but mechanism-specific action belongs to the interventional team and current ACS pathway rather than to the grade itself. | Grade 2 is complete distal filling with delayed kinetics, not normal flow. Historical cohorts associate persistent grade 2 with worse outcomes than grade 3, but the association varies by timepoint and era and cannot be converted into an individual mortality, infarct-size or myocardial-salvage estimate. | TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 2 entry-or-clearance definition; Gibson et al. 1996, PMID 8598078, CTFC continuous companion; Rao et al. 2025, DOI 10.1016/j.jacc.2024.11.009. | ✓ |
| 3 | Grade 3, complete perfusion | Original TIMI grade 3, complete perfusion: antegrade contrast enters the distal bed as promptly as it enters the bed proximal to the obstruction or a comparable uninvolved artery, and clears from the involved bed just as rapidly. Do not substitute the nonoriginal shortcut of vessel opacification within fewer than three cardiac cycles. | Record grade 3 as normal epicardial visual flow at that artery/timepoint while still assessing residual stenosis, thrombus, dissection, myocardial blush or TMPG, ST resolution, ventricular function and clinical status. Grade 3 is neither a discharge criterion nor proof that no-reflow, infarction or incomplete revascularization is absent. | Grade 3 has the most favorable epicardial-flow association in reperfusion cohorts, but tissue-level microvascular obstruction and adverse outcomes can persist. It cannot supply a personal prognosis, prove myocardial salvage or erase the presenting ACS risk. | TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 3; Gibson et al. 1999, DOI 10.1016/S0002-8703(99)70380-7, original wording and approximately 10 percentage-point overcall from the three-cycle shortcut; Gibson et al. 1996, DOI 10.1161/01.CIR.93.5.879, CTFC heterogeneity within visual grades. | ✓ |

### Citações por categoria
- **0**: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437 · TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 0; Rao et al. 2025 ACS guideline, DOI 10.1016/j.jacc.2024.11.009, syndrome/revascularization context; Gibson et al. 1996, DOI 10.1161/01.CIR.93.5.879, qualitative versus quantitative flow boundary.
- **1**: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437 · TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original penetration-without-perfusion definition; Gibson et al. 1999, PMID 10347349, preservation of original definitions; 2025 ACC/AHA multisociety ACS guideline for current care context.
- **2**: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437 · TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 2 entry-or-clearance definition; Gibson et al. 1996, PMID 8598078, CTFC continuous companion; Rao et al. 2025, DOI 10.1016/j.jacc.2024.11.009.
- **3**: TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) Trial: Phase I Findings (1985) — https://doi.org/10.1056/NEJM198504043121437 · TIMI Study Group 1985, DOI 10.1056/NEJM198504043121437, original grade 3; Gibson et al. 1999, DOI 10.1016/S0002-8703(99)70380-7, original wording and approximately 10 percentage-point overcall from the three-cycle shortcut; Gibson et al. 1996, DOI 10.1161/01.CIR.93.5.879, CTFC heterogeneity within visual grades.

## Referências cruzadas
- _fronteira compartilhada_ → [mTICI — Modified Treatment in Cerebral Infarction reperfusion grade](https://radcommons.laudos.ai/systems/mtici.md) — TIMI grades qualitative epicardial coronary flow by distal entry, complete bed filling and clearance. mTICI grades cerebral-territory reperfusion after stroke treatment. Similar numerals and wording do not create a valid crosswalk.

## Histórico de versões

| Data | Evento | Detalhe | Situação |
| --- | --- | --- | --- |
| 2026-08-12 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-11 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-10 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-09 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-08 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-07 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-06 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-05 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-04 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-03 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-02 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-08-01 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-31 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-30 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-29 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-28 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-27 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-26 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2025-02-27 | revised | The current ACC/AHA multisociety ACS guideline supplies syndrome and revascularization management context; it does not turn a TIMI flow numeral into a standalone treatment algorithm. | confirmed |
| 1999-06-01 | revised | The TIMI Study Group documented method drift: defining grade 3 as transit within three cardiac cycles overcalled normal flow by about ten percentage points compared with the original normal-reference definition. | confirmed |
| 1996-03-01 | revised | The corrected TIMI frame count added a separate continuous, vessel- and frame-rate-controlled companion measurement; it did not replace or numerically redefine the visual grade. | confirmed |
| 1985-04-04 | published | The TIMI Study Group published the original four qualitative grades of epicardial coronary flow in the phase-I trial report. | confirmed |


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> Conteúdo de referência reescrito. Confira a publicação primária vigente. Não é dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

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