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Algorithm for prevention and treatment of no-reflow. PCI=Percutaneous Coronary Intervention, SVG=Saphenous Vein Grafts, IC=Intracoronary
Source publication
The no reflow phenomenon can happen during elective or primary percutaneous coronary intervention. This
phenomenon is thought to be a complex process involving multiple factors that eventually lead to microvascular obstruction
and endothelial disruption. Key pathogenic components include distal atherothrombotic embolization, ischemic injury,
reperf...
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Citations
... For instance, some studies have suggested the use of prophylactic vasodilator drugs, such as adenosine, nitrates, and calcium channel blockers, to prevent the occurrence of the no-reflow phenomenon; however, the use of these drugs in all patients as a standard preventive measure is limited due to the potential for adverse events associated with their administration. Early risk stratification based on the no- Frontiers in Cardiovascular Medicine reflow associated ECG patterns could justify prophylaxis drug administration in high-risk patients (5,33). Furthermore, devicebased techniques, including thrombus aspiration and distal protection, when combined with stenting, have demonstrated a significant reduction in the incidence of the no-reflow phenomenon. ...
Background
The no-reflow phenomenon affects about one out of five patients undergoing Primary Percutaneous Coronary Intervention (PPCI). As the prolonged no-reflow phenomenon is linked with unfavorable outcomes, making early recognition is crucial for effective management and improved clinical outcomes in these patients. Our review study aimed to determine whether electrocardiogram (ECG) findings before PCI could serve as predictors for the occurrence of the no-reflow phenomenon.
Methods and materials
We systematically searched MEDLINE, Scopus, and Embase to identify relevant studies. The random-effect model using inverse variance and Mantel-Haenszel methods were used to pool the standardized mean differences (SMD) and odds ratios (OR), respectively.
Result
Sixteen eligible articles (1,473 cases and 4,264 controls) were included in this study. Based on our meta-analysis of baseline ECG findings, the no-reflow group compared to the control group significantly had a higher frequency of fragmented QRS complexes (fQRS) (OR (95% CI): 1.35 (0.32–2.38), P -value = 0.01), and Q-waves (OR (95% CI): 1.97 (1.01–2.94), P -value <0.001). Also, a longer QRS duration (QRSD) (SMD (95% CI): 0.72 (0.21, 1.23), p -value <0.001) and R wave peak time (RWPT) (SMD (95% CI): 1.36 (0.8, 1.93), P < 0.001) were seen in the no-reflow group. The two groups had no significant difference regarding P wave peak time (PWPT), and P wave maximum duration (Pmax) on baseline ECG.
Conclusion
Our findings suggest that prolonged QRSD, delayed RWPT, higher fQRS prevalence, and the presence of a Q wave on baseline ECG may predict the occurrence of the no-reflow phenomenon in patients undergoing PPCI.
... CSF or the no reflow phenomenon is a major adverse complication associated with PCI with the incidence of no reflow being as high as 30% in primary PCI [9]. Factors such as ischemic injury, reperfusion injury and atherothrombotic embolization all contribute to the pathogenesis of no reflow [10]. ...
... future science group10.2217/fca-2022-0085 ...
Coronary artery disease (CAD) is an inflammatory cardiovascular disease that currently serves as a major contributor to mortality worldwide. Nicardipine, a dihydropyridine calcium channel blocker, is used as a pharmacological agent to treat complications such as the no-reflow and coronary slow flow (CSF) phenomenon, owing to its vasodilatory properties in patients with CAD or acute coronary syndromes. This systematic review aimed to shed light on the efficacy of intracoronary (IC) nicardipine in treating no reflow and other complications in patients with CAD undergoing revascularization therapy. literature search was performed OF 5 Databases from inception to May 19, 2022. Complete restoration of TIMI 3 flow was also observed in 98.6% of the patients receiving IC nicardipine. A significant increase in the CBF after infusion of IC nicardipine (p < 0.05) was observed. IC nicardipine significantly increases CBF and decreases coronary vascular resistance. To formulate strong opinions regarding this mode of nicardipine administration and its efficacy in preventing no reflow, more clinical trials with a large sample size are needed.
... 7,8 An exceedingly complicated condition known as "slowed/no flow" occurs when the remaining coronary arteries receive insufficient blood flow during PCI despite no obvious angiographical evidence of blockage, spasm, or dissection of the epicardial arteries. [9][10][11] Myocardial contrast echocardiography (MCE) and cardiac magnetic resonance imaging (CT) are the diagnostic tools I use to make this diagnosis (CMRI).Because of its sensitivity and precision, CMRI is widely acknowledged as the most effective method for determining how much no-re-flow is present in a sample. But they are rarely required, as angiograms are sufficient in most cases. ...
Objective: We investigated the rate of slow/no flow during percutaneous coronary intervention, the clinical and angiographical predictor and the immediate hemodynamic role of slow / no flow. Material & Method: The cross-sectional study was done at Sandaman Provincial Hospital, the Loralai Medical Collage Loralai, Bolan University of Medical and Health Sciences Quetta for six months from 1st July, 2021 to 31st December, 2021. We included ST-elevation myocardial infarction patients who got primary percutaneous coronary intervention (PCI). Patient information, including demographic and clinical data was collected. In this study, thrombolysis in myocardial infarction was used to determine the antegrade flow. There was an evaluation of the existence, predictors, and consequences of slow/no flow in the patients. SPSS 21 was used for data analysis. Results: Among the 300 patients, 283 (80.9%) were males. There were 54 (18.0%) patients who had angiographic slow/no flow during the procedure. TIMI grades were 0 in 13 (4.33%), 1 in 16 (5.33%), and 2 in 25 (8.33%) patients in these affected groups in the study. Smoking status was significantly different between slow and no flow (p=0.023). We found significant associations between prior MI, nonappearance of pre-infarction anginal symptoms, and any cerebrovascular disease with slow/no blood flow (p<0.05). The class III or IV Killip score was significantly higher in the slow/low flow group than the normal-flow group (p<0.05). Intracoronary adenosine and epinephrine were the most often used medications for pharmacological therapy of no/slow flow. The hemodynamic instability of two of the patients (3.70%) of the ventricular tachycardia treatment (VT) cases led to their deaths, while the stability of two (3.70%) of the patients’ VTs required pharmaceutical cardioversion. Conclusion: The occurrence of slow/no flow can be predicted with a history and angiographical feature. Keywords: Slow/no flow, Primary PCI, Angiographical predictors, Hemodynamics’.
... However, no-reflow is not uncommon and is associated with increased mortality. [2][3][4] Pharmacological therapies such as vasodilators and antiplatelet agents as well as aspiration thrombectomy have shown benefit in the treatment and reduction of the risk of the no-reflow phenomenon. [5][6][7][8][9] Intracoronary glycoprotein IIb/IIIa receptor inhibitors (GPI) is associated with additional benefits compared with intravenous bolus application. ...
... 15 Although routine aspiration thrombectomy is not recommended for the management of STEMI, 1 it might be considered in cases with high thrombus burden. As diabetic patients are more prone to no-reflow and higher thrombus grades, 3,5 we investigated the benefit of GPI with vasodilators distal to the lesion via thrombus aspiration after thrombectomy among diabetic patients with STEMI and high thrombus burden. ...
Resumen
Introducción y objetivos
Estudiar el impacto de la inyección intracoronaria de eptifibatida más vasodilatadores a través de un catéter de aspiración de trombos frente a la aspiración de trombos aislada en la reducción del riesgo de ausencia de reperfusión (no-reflow) en infarto agudo de miocardio con elevación del ST (IAMCEST) con diabetes y elevada carga de trombos.
Métodos
Participaron 413 pacientes diabéticos con IAMCEST y elevada carga de trombos que se aleatorizaron a inyección intracoronaria (distal a la oclusión) de eptifibatida, nitroglicerina y verapamilo después de aspirar el trombo y previo al inflado del balón (n = 206) frente a aspiración del trombo únicamente (n = 207). El criterio de valoración principal fue el grado de blush miocárdico (GBM) y el Thrombolysis in Myocardial Infarction (TIMI) frame count corregido (cTFC). Los eventos cardiovasculares adversos mayores (MACE) se notificaron a los 6 meses.
Resultados
El grupo de eptifibatida intracoronaria y vasodilatadores fue superior a la tromboaspiración sola en lo que respecta a la MBG-3 (82,1% frente a 31,4%; p = 0,001). El grupo de eptifibatida y vasodilatadores intracoronarios locales tuvo un cTFC más corto (18,16 ± 6,54 frente a 29,64 ± 5,53; p = 0,001), y mejor flujo TIMI-3 (91,3% frente a 61,65%; p = 0,001). La eptifibatida intracoronaria y los vasodilatadores mejoraron la fracción de eyección a los 6 meses (55,2 ± 8,13 frente a 43 ± 6,67; p = 0,005). No hubo diferencia en las tasas de MACE a los 6 meses.
Conclusiones
Entre los pacientes diabéticos con IAMCEST y alta carga de trombos, la inyección intracoronaria distal de eptifibatida más vasodilatadores fue beneficiosa en prevenir la falta de reperfusión comparada con la tromboaspiración sola. Se recomiendan estudios más amplios para investigar el beneficio de esta estrategia en reducir el riesgo de eventos clínicos adversos.
... The main adverse event of the no-reflow phenomenon is the elimination of the positive effects of PCI [5]. The no-reflow phenomenon is multiple pathogenetic processes, which may be attributed to ischemic injuries, distal atherothrombotic embolization, coronarymicrocirculation susceptibility to injury, and reperfusion injuries [6]. Recently, many studies focused on thrombus aspiration to prevent the distal embolization of thrombotic/plaque material [7,8]. ...
Background: Previous trials showed a promising potential use of epinephrine in the treatment of no-reflow phenomenon (the no-reflow phenomenon is multiple pathogenetic processes, which may be attributed to ischemic injuries, distal atherothrombotic embolization, coronary-microcirculation susceptibility to injury, and reperfusion injuries (6)). This study aimed to compare the safety and efficacy of distal intracoronary delivery of epinephrine versus verapamil to prevent no-reflow during primary percutaneous coronary intervention (PPCI). Materials and Methods: We conducted a randomized, open-label, trial on patients undergoing PPCI. Patients were randomized to one of three groups: group I who received distal intracoronary administration of epinephrine; group II who received verapamil; and group III who served as a control group. The primary endpoint in our study was the incidence of no-reflow, defined as a post-procedural (Thrombolysis in Myocardial Infarction) TIMI flow grade (TFG) is < 3 or, in the case of a TFG of 3, when TIMI myocardial perfusion grade (TMPG) is 0 or 1. Results: A total of 120 patients were randomized. The angiographic flow and perfusion parameters were significantly improved in group I and II versus the control group, with better results in epinephrine group only TMPG3 was significantly higher with epinephrine (77.5%) than verapamil (55%) (p = 0.037) and TMPG2 was higher in verapamil (32.5%) than epinephrine (7.5%) (p = 0.003). No reflow is lower with epinephrine than verapamil (25% vs 27.5%); however, with no statistically significant difference (P=0.785). Patients in the three groups has no statistical significant difference in (MACE) or heart failure hospitalization. Conclusion: Epinephrine and verapamil are safe and effective in managing patients with no-reflow during PPCIs. Further studies with a larger sample and a longer duration of follow-up are required to confirm these findings
... Previous studies have shown that incidence of no-reflow phenomenon ranged from 2% to 44% among patients who underwent primary or elective PCI and mortality rate ranged from 7.4 to 30.3% in these patient populations (4)(5)(6)(7)(8)(9)(10)(11)(12). The term ''no-reflow phenomenon'' is described as disturbance of myocardial perfusion throughout a specified segment of coronary circulation without any angiographic evidence of coronary artery obstruction, spasm, or dissection (4,9). ...
... Previous studies have shown that incidence of no-reflow phenomenon ranged from 2% to 44% among patients who underwent primary or elective PCI and mortality rate ranged from 7.4 to 30.3% in these patient populations (4)(5)(6)(7)(8)(9)(10)(11)(12). The term ''no-reflow phenomenon'' is described as disturbance of myocardial perfusion throughout a specified segment of coronary circulation without any angiographic evidence of coronary artery obstruction, spasm, or dissection (4,9). Although this condition is generally diagnosed by using coronary angiography, myocardial contrast echocardiography is the gold standard method for the diagnosis of no-reflow phenomenon (10,11). ...
Objective:Percutaneous coronary intervention (PCI) has become the treatment method for patients presenting with ST elevation myocardial infarction (STEMI). One of the well-known complications of PCI is no-reflow. Studies demonstrated a relationship between endothelial dysfunction and disturbed vascular flow due to angulation of vascular tree. Although the relationship between hemodynamic alterations and coronary angulation is evident, there is a lack of detailed analysis in terms of hemodynamic changes between vascular geometry and coronary no-reflow. We aimed to elucidate the relationship between vascular geometry and coronary no-reflow.Method:We reviewed PCI database of our hospital and enrolled a total of 120 patients with STEMI, who developed no-reflow following PCI, and sex and age matched 80 patients with normal flow. For each group, demographic and clinical characteristics, laboratory values and two dimensional quantitative coronary angiography measurements were evaluated.Results:Patients with no-reflow had a higher prevalence of hypertension and diabetes mellitus. In addition, serum C-reactive protein levels were higher in patients with no-reflow compared to patients with normal flow (p
... 7,8 Slow/no flow is a phenomenon with complex pathogenesis that leads to inadequate blood flow to the distil coronary vessels after PCI without apparent evidence of angiographical epicardial vessel occlusion, spasm or dissection. [9][10][11] There are several methods to diagnose this condition, like angiography, myocardial contrast echocardiography (MCE), and cardiac magnetic resonance imaging (CMRI). The gold standard for the diagnosis of no-reflow is MCE, and CMRI is known to be the most sensitive and specific method to assess the extent of no-reflow. ...
Objectives: To determine the frequency of slow/no flow in primary percutaneous coronary intervention, to know the clinical and angiographical predictors of the phenomenon, and to investigate the immediate impact of slow/no flow on hemodynamics.
Method: The cross-sectional study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from June 2018 to July 2019, and comprised patients presenting with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention. Demographic and clinical details of the patients were recorded. The antegrade flow was assessed and determined using the thrombolysis in myocardial infarction criterion. Patients were assessed for the occurrence, predictors and impact of slow/no flow. Data was analysed using SPSS 21.
Results: Of the 559 patients, 441(78.9%) were males. The overall mean age of the sample was 55.86±11.07 years. Angiographical slow/no flow during the procedure occurred in 53 (9.5%) patients, while normal flow was achieved in 506(90.5%). The thrombolysis in myocardial infarction grade in the affected patients was 0 in 10(1.8%), 1 in 15(2.7%), and 2 in 28(5%) patients. Smoking status,
Continuous...
... In clinical practice, primary percutaneous coronary intervention (PCI) is a standard therapeutic strategy to open blocked vessels in patients with ST-segment elevation myocardial infarction (STEMI), since it shortens the total ischemic time and reduces the mortality rate. However, a few patients still suffer from myocardial postischemic injury, which is termed as the no-reflow phenomenon during or after PCI [1][2][3][4]. The potential mechanism of no-reflow phenomenon involves coronary microvascular dysfunction (CMD) which has been considered as an independent risk factor for rehospitalization and 30-day mortality in AMI patients during or after PCI therapy [5]. ...
A major shortcoming of postischemic therapy for myocardial infarction is the no-reflow phenomenon due to impaired cardiac microvascular function including microcirculatory barrier function, loss of endothelial activity, local inflammatory cell accumulation, and increased oxidative stress. Consequently, inadequate reperfusion of the microcirculation causes secondary ischemia, aggravating the myocardial reperfusion injury. ATP-sensitive potassium ion (KATP) channels regulate the coronary blood flow and protect cardiomyocytes from ischemia-reperfusion injury. Studies in animal models of myocardial ischemia-reperfusion have illustrated that the opening of mitochondrial KATP (mito-KATP) channels alleviates endothelial dysfunction and reduces myocardial necrosis. By contrast, blocking mito-KATP channels aggravates microvascular necrosis and no-reflow phenomenon following ischemia-reperfusion injury. Nicorandil, as an antianginal drug, has been used for ischemic preconditioning (IPC) due to its mito-KATP channel-opening effect, thereby limiting infarct size and subsequent severe ischemic insult. In this review, we analyze the protective actions of nicorandil against microcirculation reperfusion injury with a focus on improving mitochondrial integrity. In addition, we discuss the function of mitochondria in the pathogenesis of myocardial ischemia.
... At present, although PCI has been widely used in the clinical treatment of STEMI and has achieved a satisfactory clinical efficacy, no-reflow was still found in some patients after PCI, leading to cardiac dysfunction, left ventricular remodeling, sudden cardiac death, and other complications (9,10). The no-reflow phenomenon refers to the fact that after emergency PCI treatment, although the infarction relevant arteries (IRA) of patients have been opened, there is still no myocardial perfusion or low perfusion (11,12). The No-reflow phenomenon is a severe complication of emergency PCI; the incidence rate is as high as 25-30% (13). ...
Background:
The purpose of this study was to screen the predictive factors of no-reflow after a percutaneous coronary intervention (PCI) in elderly patients with ST-segment elevation myocardial infarction (STEMI), and to construct a nomogram model, to guide clinical treatment.
Methods:
A total of 551 elderly STEMI patients (age >65) underwent direct PCI were randomly classified into training group (n=386, 70%) and validation group (n=165, 30%). All patients in the two groups were divided into a no-reflow group and a normal blood flow group according to whether there was a no-reflow phenomenon. Univariable and multivariable logistic regression analysis was used to analyze the relevant data, including demographic characteristics, clinical characteristics, coronary angiography results, electrocardiogram (ECG) results, and biochemical indicators. Then, a nomogram model was constructed on the screened risk factors. The performance of the nomogram was evaluated in terms of discrimination and calibration. The nomogram was further confirmed in the internal validation group. Additionally, decision curve analysis (DCA) was applied to assess the clinical usefulness of the nomogram.
Results:
Five remarkable risk factors were determined: preoperative TIMI blood flow, the diameter of the target lesion, collateral circulation, pulse pressure, and the number of leads for ST-segment elevation. The nomogram involving these five risk factors showed full calibration and discrimination in the training group, with an AUC of 0.71 (95% CI: 0.66-0.77). It was confirmed in the validation group, and the entire cohort and the AUC were 0.64 (95% CI: 0.56-0.73) and 0.69 (95% CI: 0.65-0.74), respectively. Whether in the training group or the verification group, the calibration curve for the probability of no-reflow phenomenon all showed considerable consistency between prediction by nomogram and actual observation. The decision curve revealed a specific role in our nomogram in clinical practice.
Conclusions:
We set up a nomogram that showed absolute accuracy for the prediction of the risk of no-reflow after primary PCI in elderly STEMI patients.
... NRP following PPCI leads to higher 30-day mortality if not properly managed (32% vs 2.8%, p < 0.0.001) [12] and patients with TIMI flow from 0 to 2 have worse outcomes, even without significant epicardial obstruction [13], leading to prolonged myocardial ischemia and a 10-fold higher risk of clinical complications [14]. ...
The no-reflow phenomenon following primary percutaneous coronary intervention (PPCI) in acute ST-elevation myocardial infarction (STEMI) patients is a predictor of unfavorable prognosis. Patients with no-reflow have many complications during admission, and it is considered a marker of short-term mortality. The current research emphasizes the circumstances of the incidence and complications of the no-reflow phenomenon in STEMI patients, including in-hospital mortality. In this case-control study, conducted over two and a half years, there were enrolled 656 patients diagnosed with STEMI and reperfused through PPCI. Several patients (n = 96) developed an interventional type of no-reflow phenomenon. One third of the patients with a no-reflow phenomenon suffered complications during admission, and 14 succumbed. Regarding complications, the majority consisted of arrhythmias (21.68%) and cardiogenic shock (16.67%). The anterior localization of STEMI and the left anterior descending artery (LAD) as a culprit lesion were associated with the highest number of complications during hospitalization. At the same time, the time interval >12 h from the onset of the typical symptoms of myocardial infarction (MI) until revascularization, as well as multiple stents implantations during PPCI, correlated with an increased incidence of short-term complications. The no-reflow phenomenon in patients with STEMI was associated with an unfavorable short-term prognosis. Keywords: acute myocardial infarction (MI); no-reflow phenomenon (NRP); primary percutaneous coronary intervention (PPCI); thrombolysis in myocardial infarction (TIMI) risk score
