BACKGROUND: The no-reflow phenomenon is associated with a considerable reduction in myocardial salvage in patients with ST elevation myocardial infarction (STEMI) treated by primary percutaneous intervention (PCI). There has been no head-to-head comparison of intra-coronary epinephrine to adenosine in the management of no-reflow phenomenon. OBJECTIVES: Evaluate the short- and long-term efficacy and safety of using intracoronary epinephrine versus adenosine for management of the catastrophic no-reflow phenomenon that may occur during primary PCI. DESIGN: Retrospective cohort. SETTING: Single center in Egypt. PATIENTS AND METHODS: The study included STEMI patients who developed refractory no-reflow phenomenon during primary PCI after failure of conventional treatments and received either intracoronary epinephrine or adenosine. MAIN OUTCOME MEASURES: No-reflow management measured through improvement of thrombolysis in myocardial infarction grade (TIMI flow), myocardial blush grade, TIMI frame count and major adverse cardiovascular events (MACE) at 1-year follow up. SAMPLE SIZE: 156 patients with refractory no-reflow phenomenon during primary PCI. RESULTS: Successful reperfusion was achieved in 74 of 81 (91.4%) of patients who received epinephrine and in 65 of 75 (86.7%) who received adenosine ( P <.05). Fifty-six of 81 patients (69.1%) achieved TIMI III flow after epinephrine administration versus 39 of 75 patients (52.7%) in the adenosine group ( P =.04). The incidence of heart failure after 1 year of follow up was lower in the epinephrine group compared to the adenosine group (6.3% vs. 19.2%, P <.017). MACE after 1 year of follow up was lower in patients who received epinephrine compared to those who received adenosine (11.3 % Vs. 26.7 %, P <.01). CONCLUSION: During primary PCI, intracoronary epinephrine is as effective as adenosine in successful management of refractory no-reflow phenomenon with a more favorable long-term prognosis compared to adenosine. LIMITATIONS: Retrospective design. CONFLICT OF INTEREST: None.

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Background: Echocardiography is a first simple technique for the evaluation of coronary artery disease (CAD), which is useful in the diagnostic and prognostic workup of these syndromes. The clinical work-up of patients presenting with chest pain is a diagnostic challenge. Objective: We inspected the diagnostic performance of global (GLS) and territorial (TLS) longitudinal strain to predict CAD in patients presenting with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) but apparent normal global and regional systolic function. Patients And Method: A cross sectional study included 90 patients with suspected NSTE-ACS with normal left ventricular ejection fraction (LVEF) (≥50%) and wall motion score index (WMSI) (=1). Speckle-tracking echocardiography was performed to all patients on admission then patients underwent coronary angiography or noninvasive test according to their risk stratification. Patients were classified to 2 groups (CAD and No CAD). Results: There was significant sensitivity and specificity of cardiac enzymes, GRACE score, Global longitudinal strain and territorial longitudinal strain in identifying CAD. However there was no statistically significant difference in conventional echocardiographic data between both studied groups. A cutoff value of GLS -17.1, TLS-LAD cutoff level >-17.15, TLS-LCX cutoff level >-16.9 and TLS-RCA cutoff level >-16.3. GLS as a predictor for the number of affected vessels, cutoff point of ≥ -15.4 can be used. A predictor for the presence of proximal lesions, cutoff point of TLS LAD ≥ -15.1 and TLS LCX ≥-15.3 can be used. Conclusions: Global longitudinal strain and territorial longitudinal strain can be used for early detection of the presence of coronary artery occlusion to identify patients who may benefit from early reperfusion. GLS also can predict multivessel disease and TLS can be used as a predictor for the presence of proximal lesions.

Background: Diagnosis of coronary artery disease (CAD) is of importance in the contemporary society of everincreasing CAD (1,2). Isovolumic relaxation velocity (VIR), Postsystolic motion or postsystolic shortening (PSS) is a delayed ejection motion of the myocardium occurring after the aortic valve closure during a generally prolonged isovolumic relaxation time, which is related with myocardial ischemia in human (3,4) and in experimental studies (5). Spectral tissue Doppler imaging (TDI) is a simple echocardiographic technique that can provide velocity measurement of the myocardial segments (6). A positive myocardial velocity during isovolumic relaxation phase (VIR) detected by TDI, which corresponds to postsystolic motion or PSS, has been shown to indicate severely ischemic myocardium (8). So, detection of positive VIR by spectral TDI may be used as a noninvasive, nonprovocative method to predict possible CAD; specially for those with coexisting morbidities, such as peripheral artery disease in the lower limb, orthopedic diseases. Aim of the work: Diagnostic value of positive myocardial velocity during isovolumic relaxation phase (VIR) by spectral TDI in prediction of CAD in patients with typical ischemic chest pain and normal resting wall motions. Patients and methods: This study was done in Cardiology department, Zagazig University on 80 patients; 41 females (51%) & 39 males (49%)) with typical ischemic chest pain and no regional wall motion abnormalities detected by resting echocardiography. Patients were divided into 2 groups according to presence of significant coronary artery lesion by coronary angiography; group A (patients with CAD) and group B (patients without CAD). All the following parameters were measured by TDI; 5 peak velocities during; Isovolumic contraction phase (VIC), Systolic ejection phase (S'), Early diastolic relaxation phase (Em), Atrial contraction phase (Am) and Isovolumic relaxation phase (VIR) if present and VIR time. Then coronary angiography was done for all patients. Results: As regard to presence of VIR velocity, there was significant difference (<0.05) between group A and group B at mid septal and anterior walls, highly significant difference (<0.001) at basal septal and anterior walls. There was highly significant difference between group A and B at mid and basal lateral and inferior walls. There was highly significant correlation between coronary angiography and VIR velocity regarding detection of positive and negative cases and also there was highly significant correlation between previous 2 tests by Kappa test p value (<0.001). Conclusion: Positive VIR detected by spectral tissue Doppler imaging is a useful indicator of CAD in patients with apparently normal left ventricular contraction and chest pain.

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