The challenges of coronary no‐reflow phenomenon

Case, Brian C.; Satler, Lowell F.

doi:10.1002/ccd.29571

Cited by 5 publications

(6 citation statements)

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“…Studies have shown that the occurrence of NR during PPCI is related to various mechanisms, including thrombus or plaque embolization leading to microcirculation obstruction, microcirculation reperfusion injury, and microcirculation spasm in the coronary arteries [ 15 ]. Currently, there is no single effective method to prevent NR, although research suggests that drugs such as nitroprusside, verapamil, nicorandil, tirofiban, and adrenaline [ 16 , 17 ], as well as non-pharmacological approaches such as thrombus aspiration, distal protection devices, and MGuard stents, may help reduce or prevent NR [ 18 , 19 ]. However, the evidence in the field of evidence-based medicine is still inconclusive.…”

Section: Discussionmentioning

confidence: 99%

Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction Patients After Percutaneous Coronary Intervention: Influencing Factors and Intervention Strategies

Tang¹,

Chen²,

Li³

et al. 2023

Cureus

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Aim We aim to explore the factors influencing myocardial perfusion in patients with acute ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI) and evaluate the effects of different intervention strategies on myocardial perfusion improvement. Methods A retrospective analysis was conducted on 300 patients with STEMI who underwent primary percutaneous coronary intervention (PPCI) at our hospital between January 2020 and December 2022. Based on post-procedural coronary angiography results using the thrombolysis in myocardial infarction (TIMI) blood flow grade and myocardial blush grade (MBG), patients were categorized into two groups: the normal perfusion group (TIMI grade 3 or MBG 2-3, n=180) and the impaired perfusion group (TIMI grades 0-2 or MBG 0-1, n=120). The impaired perfusion group was further divided using a random number table into the thrombus aspiration-only group (control group, n=60) and the thrombus aspiration combined with nicorandil group (nicorandil group, n=60). A 1:1 propensity score matching method was employed to adjust for baseline characteristics between the groups. Clinical characteristics, hematological parameters, coronary lesion features, and percutaneous coronary intervention (PCI) technical parameters were compared between the matched groups. Additionally, a multivariate logistic regression analysis was performed to identify independent risk factors influencing myocardial perfusion. Furthermore, the post-procedural myocardial perfusion, cardiac function, and clinical prognosis were compared between the control and nicorandil groups. Results After matching, the baseline characteristics of the two groups were compared. The impaired perfusion group had older age, higher proportion of male patients, higher rates of diabetes and hypertension, longer time from symptom onset to balloon dilation, higher peak cardiac troponin I (cTnI) levels, higher proportion of left main or multivessel involvement, heavier coronary lesion burden, and lower balloon inflation pressure (P<0.05). Multivariate logistic regression analysis revealed that age of ≥65 years (odds ratio {OR}=2.34, 95% confidence interval {CI}=1.23-4.46, P<0.01), time from symptom onset to balloon dilation of ≥6 hours (OR=3.12, 95% CI=1.67-5.83, P<0.01), peak cTnI level of ≥100 ng/mL (OR=4.27, 95% CI=2.18-8.36, P<0.01), left main or multivessel involvement (OR=2.86, 95% CI=1.51-5.41, P<0.01), and balloon inflation pressure of <8 atm (OR=3.45, 95% CI=1.79-6.65, P<0.01) were independent risk factors affecting myocardial perfusion. In the intervention analysis, the nicorandil group showed superior post-procedural TIMI blood flow grade, MBG, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) functional classification compared to the control group (P<0.05). During a six-month follow-up, the nicorandil group had a lower incidence of major adverse cardiovascular events (MACE) compared to the control gro...

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Section: Discussionmentioning

confidence: 99%

Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction Patients After Percutaneous Coronary Intervention: Influencing Factors and Intervention Strategies

Tang¹,

Chen²,

Li³

et al. 2023

Cureus

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“…More recently, the COAR trial, an open-labeled study that randomized patients to intracoronary epinephrine vs. adenosine, was published, demonstrating improved end coronary flow and relative safety of epinephrine in normotensive patients with acute coronary syndrome [66]. The main side effect of epinephrine is the risk of developing malignant arrhythmias [67]. Figure 2 represents a case of no refractory reflow management handled at our center.…”

Section: Epinephrinementioning

confidence: 99%

“No-Reflow” Phenomenon: A Contemporary Review

Annibali

Scrocca

Aranzulla

et al. 2022

JCM

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Primary percutaneous angioplasty (pPCI), represents the reperfusion strategy of choice for patients with STEMI according to current international guidelines of the European Society of Cardiology. Coronary no-reflow is characterized by angiographic evidence of slow or no anterograde epicardial flow, resulting in inadequate myocardial perfusion in the absence of evidence of mechanical vessel obstruction. No reflow (NR) is related to a functional and structural alteration of the coronary microcirculation and we can list four main pathophysiological mechanisms: distal atherothrombotic embolization, ischemic damage, reperfusion injury, and individual susceptibility to microvascular damage. This review will provide a contemporary overview of the pathogenesis, diagnosis, and treatment of NR.

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Section: Introductionmentioning

confidence: 99%

“…1 However, they are ineffective in restoring coronary flow in a substantial number of patients (refractory no-reflow phenomenon); furthermore, their use is limited by hypotension, a major consequence of the no-reflow. 5 Epinephrine can mediate coronary vasodilatation at lower doses and increase inotropic and chronotropic stimulation of the myocardium through activating beta receptors. 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.…”

Section: Introductionmentioning

confidence: 99%

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

Afshar

Samimisedeh

Tayebi

et al. 2023

Therapeutic Advances in Cardiovascular Disease

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Background: Currently, no pharmacological or device-based intervention has been fully proven to reverse the no-reflow phenomenon. Objectives: To assess the efficacy and safety of intracoronary (IC) epinephrine in the management of no-reflow phenomenon following percutaneous coronary intervention (PCI), either as first-line treatment or after the failure of conventional agents. Design: Systematic review. Data sources and methods: PubMed and Scopus databases were systematically searched up to 28 May 2022, with additional manual search on the Google Scholar and review of the reference lists of the relevant studies to identify all published studies. Cohort studies, case series, and interventional studies written in English which evaluated the efficacy and safety of IC epinephrine in patients with no-flow phenomenon were included in our review. Results: Six of the 646 articles identified in the initial search met our inclusion criteria. IC epinephrine was used either as a first-line treatment [two randomized clinical trials (RCTs)] or after the failure of conventional agents (two cohort studies and two case series) for restoring the coronary flow, mainly after primary PCI. As first-line therapy, IC epinephrine successfully restored coronary flow in over 90% of patients in both RCTs, which significantly outperformed IC adenosine (78%) but lagged behind combination of verapamil and tirofiban (100%) in this regard. In the refractory no-flow phenomenon, successful reperfusion [thrombolysis in myocardial infarction (TIMI) flow grade = 3] was achieved in three out of four patients after the administration of IC epinephrine based on the results from both case series. Their findings were confirmed by a recent cohort study that further compared IC epinephrine with IC adenosine and found significant differences between them in terms of efficacy [% TIMI flow grade 3: (69.1% versus 52.7%, respectively; p value = 0.04)] and 1-year major adverse cardiac event (MACE) outcomes (11.3% versus 26.7%, respectively; p value ⩽ 0.01). Overall, malignant ventricular arrhythmias were reported in none of the patients treated with IC epinephrine. Conclusion: Results from available evidence suggest that IC epinephrine might be an effective and safe agent in managing the no-reflow phenomenon.

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The challenges of coronary no‐reflow phenomenon

Cited by 5 publications

References 4 publications

Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction Patients After Percutaneous Coronary Intervention: Influencing Factors and Intervention Strategies

Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction Patients After Percutaneous Coronary Intervention: Influencing Factors and Intervention Strategies

“No-Reflow” Phenomenon: A Contemporary Review

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

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