Intracoronary epinephrine versus adenosine in the management of refractory no-reflow phenomenon: a single-center retrospective cohort study

Abstract

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.

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 ).…”

“…Darwish et al 8 conducted the second cohort study in 2022 and found that a higher percentage of patients who were treated with IC epinephrine achieved successful reperfusion (TFG = 3) compared with those with IC adenosine (69.1% versus 52.7%, respectively; p value = 0.04). During hospitalization, sustained ventricular tachycardia was observed in one of the patients in the epinephrine group.…”

“…Furthermore, observational studies found that IC epinephrine was effective and without serious complications in treating most cases with the refractory no-reflow phenomenon. 7 – 10 …”

“… 6 Hence, previous studies have attempted to identify if intracoronary (IC) epinephrine could be considered as a potential solution to refractory coronary no-reflow during PCI. 7 – 10 …”

“…6 Hence, previous studies have attempted to identify if intracoronary (IC) epinephrine could be considered as a potential solution to refractory coronary no-reflow during PCI. [7][8][9][10] Also, recent studies have provided evidence for using IC epinephrine as first-line therapy in the no-reflow phenomenon management. 6,11 We conducted a systematic review of available evidence to assess IC epinephrine's clinical efficacy and safety in treating patients suffering from no-reflow following PCI, as a first-line treatment, or after the failure of current conventional agents.…”