Intracoronary verapamil for reversal of no‐reflow during coronary angioplasty for acute myocardial infarction

Abstract

No-reflow is a frequent observation during direct PTCA for acute myocardial infarction (AMI) and associated with a poor clinical outcome. This study assesses the value of verapamil for reversal of no-reflow during PTCA for AMI. In a consecutive series of 212 direct or rescue PTCAs for AMI, a TIMI flow grade < 3 was observed in 23 patients (10.8%). Ten of these patients had received GP IIb/IIIa antagonists before PTCA. Seven patients with AMI and TIMI grade 3 flow served as controls. All lesions were treated by stents. In 18 patients with systolic blood pressure > 90 mm Hg, nitroglycerine (0.1 mg i.c.) was given. Verapamil (1 mg over 2 min) was given via an infusion catheter distal to the angioplasty site. Before and after nitroglycerine, after verapamil, and 15 min later coronary flow was assessed by the TIMI frame count method (TFC). Nitroglycerine had no effect on TFC. Verapamil reduced TFC from 56 +/- 9 frames to 24 +/- 4 (P < 0.001). In controls, TFC did not change significantly. The TIMI flow grade was restored to TIMI flow grade 3 in 65%. In two of seven right coronary and one of three circumflex arteries, intermittent AV block II occurred during verapamil injection, which disappeared after atropine. No-reflow after PTCA for AMI can be reversed by intracoronary verapamil. This supports the hypothesis that no-reflow is caused by acute microvascular dysfunction probably because of a disorder in calcium homeostasis or microvascular spasm.

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

“…Evidence for a beneficial effect on no-reflow exists for abciximab, adenosine, nicorandil, and nitroprusside. 674,675,680,682,683,685,687,688,690 However, their adoption into clinical practice has depended on their effect on hard clinical endpoints such as infarct size and mortality. These benefits, and consequentially the use of these agents, have been limited.…”

Effects of a Distal Protection Device During Primary Stenting in Patients With Acute Anterior Myocardial Infarction

“…Although primary stenting is the most reliable strategy, the no-reflow phenomenon does occur in some patients. Investigators have reported the management of no-reflow, [20][21][22][23] but few preventive therapies for no-reflow in AMI have been described. Recently, Limbruno et al reported the effectiveness and safety of the non-occlusive filter type distal protection device (FilterWire-Ex ® ) during PCI in AMI caused by native coronary obstruction; 24 however, the effects of the filter type protection device for LV function remain uncertain because of the variation in IRAs in that study.…”

Vasoconstrictor Potential of Coronary Aspirate From Patients Undergoing Stenting of Saphenous Vein Aortocoronary Bypass Grafts and Its Pharmacological Attenuation

“…Intracoronary nitroprusside has the advantage of having no hemodynamic side-effects. 49,50 In contrast, intracoronary verapamil can cause bradyarrhythmias, 51,52 but it may also attenuate stunning 53 and contribute to a reduction of infarct size. 54 Also, the half-life of verapamil is longer, and it does not require continuous intracoronary infusion.…”