Comparison of Intracoronary Epinephrine and Adenosine for No-Reflow in Normotensive Patients With Acute Coronary Syndrome (COAR Trial)

Abstract

Background: Intracoronary epinephrine has been effectively used in treating refractory no-reflow, but there is a dearth of data on its use as a first-line drug in normotensive patients in comparison to the widely used adenosine. Methods: In this open-labeled randomized clinical trial, 201 patients with no-reflow were randomized 1:1 into intracoronary epinephrine as the treatment group and intracoronary adenosine as the control group and followed for 1 month. The primary end points were improvement in coronary flow, as assessed by TIMI (Thrombolysis in Myocardial Infarction) flow, frame counts, and myocardial blush. Secondary end points were in-hospital and short-term mortality and major adverse cardiac events. Results: In all, 101 patients received intracoronary epinephrine and 100 patients received adenosine. Epinephrine was generally well tolerated with no immediate table death or ventricular fibrillation. No-reflow was more effectively improved with epinephrine with final TIMI III flow (90.1% versus 78%, P =0.019) and final corrected TIMI frame count (24±8.43 versus 26.63±9.22, P =0.036). However, no significant difference was observed in final grade III myocardial blush (55.4% versus 45%, P =0.139), mean reduction of corrected TIMI frame count (−25.71±11.79 versus −26.08±11.71, P =0.825), in-hospital and short-term mortality, and major adverse cardiac events. Conclusions: Epinephrine is relatively safe to use in no-reflow in normotensive patients. A significantly higher frequency of post-treatment TIMI III flow grade and lower final corrected TIMI frame count with relatively better achievement of myocardial blush grade III translate into it displaying relatively better efficacy than adenosine. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04699110.

Efficacy and safety of intracoronary epinephrine for the management of the no-reflow phenomenon following percutaneous coronary interventions: a systematic-review study

“…We identified 646 articles in the initial search. After removal of duplicates ( n = 116) and excluding ineligible articles (title / abstract: n = 498, full-text: n = 28) and addition of two citations from the Google Scholar survey, six articles met our inclusion criteria; included studies focused on efficacy and safety of IC epinephrine as a first-line treatment ( n = 2) 6 , 11 or after failure of other conventional agents ( n = 4) 7 – 10 for the treatment of patients with no-reflow phenomenon. Studies were conducted in Egypt ( n = 2), Poland ( n = 1), Pakistan ( n = 1), the United States ( n = 1), and Turkey ( n = 1) ( Table 1 ).…”

“…Khan et al 6 compared the efficacy and safety of IC epinephrine with adenosine for the treatment of the no-reflow phenomenon, mainly after PPCI. They found that patients in the epinephrine group experienced more frequently TFG = 3 (90% versus 78%, respectively) and MBG = 3 (55% versus 45%, respectively).…”

“…As a first-line treatment, Khan et al. 6 reported that IC epinephrine compared with IC adenosine showed a higher efficacy in resolving the no-reflow phenomenon. However, Hafez et al.…”

“…Also, recent studies have provided evidence for using IC epinephrine as first-line therapy in the no-reflow phenomenon management. 6 , 11…”

Intracoronary Administration of Drugs in Clinical Practice

“…Одним з останніх досліджень з цього приводу було дослідження COAR Trial щодо порівняння інтракоронарного аденозину та адреналіну для лікування ФДМ у пацієнтів з нормальним тиском на тлі ГКС. І висновок був дещо неочікуваним, а саме те, що адреналін безпечний для застосування в пацієнтів з нормальним тиском та, більше того, асоціювався з кращою ефективністю, ніж аденозин за оцінкою кровоплину та міокардіального блашу в разі лікування no-reflow [21]. Ми знаємо, що адреналін дає позитивний хронотропний та інотропний ефекти, але саме через бета-2-адренорецептори опосередковується його дія у вигляді коронарної вазодилатації.…”