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| __NOTOC__
| | #Redirect[[No-reflow phenomenon]] |
| {{SI}}
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| {{CMG}}; Jennifer Giuseffi, M.D.; David M. Leder, M.D.; {{AO}}
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| ==Overview==
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| Many definitions have been given to this phenomenon based on individual's area of specialty, but the definition that unites all fields was by Kloner et al in 1974 who described the condition as the inability to adequately perfuse myocardium after temporary occlusion
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| of an epicardial coronary artery without evidence of persistent mechanical obstruction, thus implying ongoing myocardial ischaemia.
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| No-reflow phenomenon refers to inadequate myocardial perfusion with evidence of persistent [[myocardial ischemia]] of a target vessel following [[thrombolysis]] or [[PCI|percutaneous coronary intervention (PCI)]] without angiographic evidence of mechanical obstruction.
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| In other words, it is the failure of blood to reperfuse an ischemic area after the physical obstruction has been removed or bypassed.<ref name="urlMedscape & eMedicine Log In">{{cite web |url=http://www.medscape.com/viewarticle/543911_3 |title=Medscape |format= |work=|accessdate=}}</ref><ref name="pmid17592194">{{cite journal |author=Kishi T, Yamada A, Okamatsu S, Sunagawa K |title=Percutaneous coronary arterial thrombectomy for acute myocardial infarction reduces no-reflow phenomenon and protects against left ventricular remodeling related to the proximal left anterior descending and right coronary artery |journal=Int Heart J |volume=48 |issue=3 |pages=287–302 |year=2007|month=May |pmid=17592194 |doi= 10.1536/ihj.48.287|url=http://joi.jlc.jst.go.jp/JST.JSTAGE/ihj/48.287?from=PubMed |format={{dead link|date=April 2009}} – <sup>[http://scholar.google.co.uk/scholar?hl=en&lr=&q=intitle%3APercutaneous+coronary+arterial+thrombectomy+for+acute+myocardial+infarction+reduces+no-reflow+phenomenon+and+protects+against+left+ventricular+remodeling+related+to+the+proximal+left+anterior+descending+and+right+coronary+artery&as_publication=Int+Heart+J&as_ylo=2007&as_yhi=2007&btnG=SearchScholar search]</sup>}}</ref> No-reflow is an important predictor of [[mortality]] after PCI <ref name="pmid12514653">{{cite journal| author=Resnic FS, Wainstein M, Lee MK, Behrendt D, Wainstein RV, Ohno-Machado L et al.| title=No-reflow is an independent predictor of death and myocardial infarction after percutaneous coronary intervention. | journal=Am Heart J | year= 2003 | volume= 145|issue= 1 | pages= 42-6 | pmid=12514653 | doi=10.1067/mhj.2003.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12514653 }} </ref>.
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| ==Historical Perspective==
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| This phenomenon was first described by Krug et al <ref name="Krug-1966">{{Cite journal | last1 = Krug | first1 = A. | last2 = Du Mesnil de Rochemont | first2 = G. | last3 = Korb | first3 = . | title = Blood supply of the myocardium after temporary coronary occlusion. | journal = Circ Res | volume = 19 | issue = 1 | pages = 57-62 | month = Jul | year = 1966 | doi = | PMID = 5912914 }}</ref> during induced myocardial infarction in dog subjects in 1966, but the term 'no-reflow' was first used by Majno and colleagues in 1967 when they observed that brains of rabbits exposed to prolonged ischemia suffered significant changes in the microvasculature which impeded blood flow to the brain cells.
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| ==Pathophysiology==
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| ====Distal embolization of plaques and/or thrombus====
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| The primary mechanism of no-reflow is likely due to distal [[embolization]] of [[atheromatous]] and [[thrombotic]] debris dislodged by [[balloon inflation]] or [[stent]] implantation.<ref name="Henriques-2002">{{Cite journal | last1 = Henriques | first1 = JP. | last2 = Zijlstra | first2 = F. | last3 = Ottervanger | first3 = JP. | last4 = de Boer | first4 = MJ. | last5 = van 't Hof | first5 = AW. | last6 = Hoorntje | first6 = JC. | last7 = Suryapranata | first7 = H. | title = Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. | journal = Eur Heart J | volume = 23 | issue = 14 | pages = 1112-7 | month = Jul | year = 2002 | doi = 10.1053/euhj.2001.3035 | PMID = 12090749 }}</ref>
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| Predictors of no-reflow include a higher [[plaque]] burden, [[thrombus]], [[lipid]] pools by [[IVUS]], higher[[lesion]] elastic [[membrane]] cross-sectional area, pre-[[infarction]] [[angina]], and [[TIMI flow grade]] 0 on the initial [[coronary angiogram]], among other factors. Compared to [[aspirate]]s obtained from patients without no-reflow, analysis of [[aspirate]]s obtained from patients who developed no reflow contained more [[atheromatous plaque]] and significantly more [[platelet]] and [[fibrin]]complex,[[macrophage]]s, and [[cholesterol]] crystals. The 30-day [[mortality]] was significantly higher (27.5%) in patients with no-reflow phenomenon than in patients with normal [[coronary blood flow]] after PCI (5.3%, P < 0.001).
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| Other pathophysiologic mechanisms include:
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| * Release of active tissue factor from the dislodged plaque<ref name="Bonderman-2002">{{Cite journal | last1 = Bonderman | first1 = D. | last2 = Teml | first2 = A. | last3 = Jakowitsch | first3 = J. | last4 = Adlbrecht | first4 = C. | last5 = Gyöngyösi | first5 = M. | last6 = Sperker | first6 = W. | last7 = Lass | first7 = H. | last8 = Mosgoeller | first8 = W. | last9 = Glogar | first9 = DH. | title = Coronary no-reflow is caused by shedding of active tissue factor from dissected atherosclerotic plaque. | journal = Blood | volume = 99 | issue = 8 | pages = 2794-800 | month = Apr | year = 2002 | doi = | PMID = 11929768 }}</ref>
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| * Vasoconstriction secondary to [[serotonin]], [[adenosine diphosphate]], [[thromboxane A2]], released by the embolized [[platelet]]-rich [[atheromatous]] material<ref name="Gregorini-1999">{{Cite journal | last1 = Gregorini | first1 = L. | last2 = Marco | first2 = J. | last3 = Kozàkovà | first3 = M. | last4 = Palombo | first4 = C. | last5 = Anguissola | first5 = GB. | last6 = Marco | first6 = I. | last7 = Bernies | first7 = M. | last8 = Cassagneau | first8 = B. | last9 = Distante | first9 = A. | title = Alpha-adrenergic blockade improves recovery of myocardial perfusion and function after coronary stenting in patients with acute myocardial infarction. | journal = Circulation | volume = 99 | issue = 4 | pages = 482-90 | month = Feb | year = 1999 | doi = | PMID = 9927393 }}</ref>
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| * Reperfusion injury from the release of oxygen free radicals during inflammation
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| * Myocardial necrosis and stunning
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| * Microvascular damage<ref name="Kloner-1980">{{Cite journal | last1 = Kloner | first1 = RA. | last2 = Rude | first2 = RE. | last3 = Carlson | first3 = N. | last4 = Maroko | first4 = PR. | last5 = DeBoer | first5 = LW. | last6 = Braunwald | first6 = E. | title = Ultrastructural evidence of microvascular damage and myocardial cell injury after coronary artery occlusion: which comes first? | journal = Circulation | volume = 62 | issue = 5 | pages = 945-52 | month = Nov | year = 1980 | doi = | PMID = 7418179 }}</ref>
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| * Microvascular plugging with [[platelets]] or [[leukocytes]]
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| * Endothelial swelling and tissue edema compressing vasculature
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| ==Causes==
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| ==Differentiating No Reflow Phenomenon from Slow Flow==
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| ==Epidemiology and Demographics==
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| The prevalance of no flow and slow flow varies according to definition. It has been reported in anywhere from 11-30% of patients following[[thrombolysis]] or intervention in [[acute myocardial infarction]]. However, in routine, elective coronary intervention, the prevalence has been reported to be as low as 0.6-2%. This phenomenon appears to be more frequent during interventions on [[SVG|saphenous vein grafts (SVG)]] or thrombus containing lesions as well as during the use of rotational [[atherectomy]].
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| Gender does not appear to play a role in this phenomenon, but it seems to occur more frequently in older patients and in those who did not experience pre-infarct [[angina]]. Admission [[hyperglycemia]] has also been associated with higher incidence of [[no reflow]] as well as worse outcomes. Lesions at high-risk for [[no reflow]] and slow flow include: [[diffuse]] [[atherosclerotic]] involvement, angiographic demonstrable [[thrombus]], irregular or ulcerative lesions, and long lesions with large plaque volume.
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| No reflow is a common (15%) finding during primary[[angioplasty]] for [[acute MI]].
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| ==Natural History, Complications and Prognosis==
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| No reflow often appears suddenly, is associated with severe chest pain, ischemic ECG changes, and/or hemodynamic deterioration. This needs to be distinguished from slow flow, which can be caused by coronary dissection, macrothrombus formation, coronary vasospasm, or distal macroembolization.
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| The presence of no reflow is clinically important as its presence has been associated with a five to ten fold increase in mortality, as well as a high incidence of myocardial infarction (MI), left ventricular dysfunction, ventricular arrhythmias, early congestive heart failure and cardiogenic shock.
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| ==Diagnosis==
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| ==Treatment==
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| ===Medical Therapy===
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| Restore normal blood flow through epicardial coronary arteries & microvasculature to prevent persistence of myocardial ischemia. No reflow needs to be distinguished from slow flow resulting from coronary artery dissection, thrombus, coronary vasospasm, or residual stenosis. These etiologies must be excluded as part of the treatment of no reflow. Ultimately, the goals are to improve outcomes, relieve chest pain and alleviate myocardial ischemia.
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| ===Intracoronary Pharmacotherapy===
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| [[Intracoronary Pharmacotherapy|Intracoronary]] or intragraft [[nitroprusside]], [[adenosine]], [[verapamil]], [[nicardipine]], [[GP IIb/IIIa inhibitor]]s, [[fibrinolytic therapy]] and [[aspiration]] of [[atherosclerotic]] debris are some of the treatment strategies that have been used to correct the episodes of no-reflow.
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| Thrombus aspiration catheters may be used in high-risk patients undergoing primary [[PCI]] for [[STEMI]] with occlusion or high thrombus burden. The EXPIRA study<ref name="pmid19161878">{{cite journal |author=Sardella G, Mancone M, Bucciarelli-Ducci C, ''et al.''|title=Thrombus aspiration during primary percutaneous coronary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (thrombectomy with export catheter in infarct-related artery during primary percutaneous coronary intervention) prospective, randomized trial|journal=J. Am. Coll. Cardiol. |volume=53 |issue=4 |pages=309–15 |year=2009 |month=January |pmid=19161878|doi=10.1016/j.jacc.2008.10.017|url=}}</ref> published in 2009 showed the use of a thrombus aspiration catheter in anterior [[STEMI]]patients improves myocardial perfusion, reduces infarct size by cardiac MRI and reduces cardiac death at nine months. Care should be exercised when aspirating in the proximal[[LAD]] or proximal [[circumflex]] locations so that clot does not go down the other adjacent artery.
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| Distal protection devices may be used in SVGs to prevent distal [[embolization]] of clot, debris, and vasoactive mediators. However, the Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberated Debris (EMERALD) and the Protection Devices in PCI Treatment of Myocardial Infarction for Salvage of Endangered Myocardium (PROMISE) trials showed inconsistent results with regards to embolic protection devices in use for primary PCI of native vessels.
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| Systemic [[glycoprotein IIb/IIIa]] receptor antagonists are recommended as pre-treatment in patients presenting with unstable coronary syndromes undergoing PCI. The TITAN-TIMI 34 trial showed early initiation of [[eptifibatide]] in the emergency room prior to primary PCI improved myocardial perfusion without an increased risk of bleeding.
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| A recent study by Zhao JL et al in 2009 showed patients presenting with acute MI and hyperglycemia had lower incidence of [[no reflow]] if they were pretreated with [[HMG-CoA reductase]] inhibitors prior to angiography.
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| ===Prevention===
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| When intervening on high-risk lesions (see above for description), limit the amount of instrumentation within the target vessel, which includes minimizing overaggressive balloon or [[stent]] expansion. In patients undergoing rotational [[atherectomy]], shorter runs, slower speeds and smaller initial burr size with small stepwise increases in burr size should be employed to help prevent [[no reflow]]. In addition, a cocktail of [[heparin]], [[nitroglycerin]] and [[calcium channel blockers|calcium channel blockers (CCB)]] should be infused simultaneously. Adding two [[arteriolar vasodilators]], i.e. [[nicardipine]] and [[adenosine]], to the flush "cocktail" may be helpful in further reducing incidence of no reflow, however traditionally the CCB used is [[verapamil]].
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| ==ACCF/AHA/SCAI 2011 Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]] |volume=58|issue=24|pages=2550–83|year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>==
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| ===No-Reflow Pharmacological Therapies (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]]|volume=58 |issue=24|pages=2550–83|year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>===
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Administration of an [[vasodilator|intracoronary vasodilator]] ([[adenosine]], [[calcium channel blocker]], or [[nitroprusside]]) is reasonable to treat PCI-related [[No reflow phenomenon|no-reflow]] that occurs during primary or elective PCI.<ref name="pmid17070151">{{cite journal |author=Amit G, Cafri C, Yaroslavtsev S, Fuchs S, Paltiel O, Abu-Ful A, Weinstein JM, Wolak A, Ilia R, Zahger D |title=Intracoronary nitroprusside for the prevention of the no-reflow phenomenon after primary percutaneous coronary intervention in acute myocardial infarction. A randomized, double-blind, placebo-controlled clinical trial|journal=[[American Heart Journal]] |volume=152 |issue=5 |pages=887.e9–14 |year=2006|month=November|pmid=17070151|doi=10.1016/j.ahj.2006.05.010|url=http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(06)00458-3|accessdate=2011-12-15}}</ref><ref name="pmid10973014">{{cite journal |author=Assali AR, Sdringola S, Ghani M, Denkats AE, Yepes A, Hanna GP, Schroth G, Fujise K, Anderson HV, Smalling RW, Rosales OR|title=Intracoronary adenosine administered during percutaneous intervention in acute myocardial infarction and reduction in the incidence of "no reflow" phenomenon |journal=[[Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions]] |volume=51 |issue=1 |pages=27–31; discussion 32|year=2000 |month=September|pmid=10973014|doi= |url=http://dx.doi.org/10.1002/1522-726X(200009)51:1<27::AID-CCD7>3.0.CO;2-0|accessdate=2011-12-15}}</ref><ref name="pmid15065143">{{cite journal |author=Barcin C, Denktas AE, Lennon RJ, Hammes L, Higano ST, Holmes DR, Garratt KN, Lerman A|title=Comparison of combination therapy of adenosine and nitroprusside with adenosine alone in the treatment of angiographic no-reflow phenomenon |journal=[[Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions]] |volume=61 |issue=4 |pages=484–91|year=2004 |month=April|pmid=15065143|doi=10.1002/ccd.20010|url=http://dx.doi.org/10.1002/ccd.20010 |accessdate=2011-12-15}}</ref><ref name="pmid18928946">{{cite journal|author=Fischell TA, Haller S, Pulukurthy S, Virk IS|title=Nicardipine and adenosine "flush cocktail" to prevent no-reflow during rotational atherectomy|journal=[[Cardiovascular Revascularization Medicine : Including Molecular Interventions]] |volume=9|issue=4|pages=224–8|year=2008 |pmid=18928946|doi=10.1016/j.carrev.2008.03.002|url=http://linkinghub.elsevier.com/retrieve/pii/S1553-8389(08)00118-8|accessdate=2011-12-15}}</ref><ref name="pmid11300444">{{cite journal |author=Hillegass WB, Dean NA, Liao L, Rhinehart RG, Myers PR|title=Treatment of no-reflow and impaired flow with the nitric oxide donor nitroprusside following percutaneous coronary interventions: initial human clinical experience|journal=[[Journal of the American College of Cardiology]] |volume=37 |issue=5 |pages=1335–43|year=2001|month=April |pmid=11300444|doi=|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(01)01138-X|accessdate=2011-12-15}}</ref><ref name="pmid17034064">{{cite journal |author=Huang RI, Patel P, Walinsky P, Fischman DL, Ogilby JD, Awar M, Frankil C, Savage MP|title=Efficacy of intracoronary nicardipine in the treatment of no-reflow during percutaneous coronary intervention|journal=[[Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions]] |volume=68|issue=5 |pages=671–6 |year=2006|month=November|pmid=17034064 |doi=10.1002/ccd.20885|url=http://dx.doi.org/10.1002/ccd.20885|accessdate=2011-12-15}}</ref><ref name="pmid10080465">{{cite journal |author=Ito H, Taniyama Y, Iwakura K, Nishikawa N, Masuyama T, Kuzuya T, Hori M, Higashino Y, Fujii K, Minamino T|title=Intravenous nicorandil can preserve microvascular integrity and myocardial viability in patients with reperfused anterior wall myocardial infarction |journal=[[Journal of the American College of Cardiology]] |volume=33 |issue=3 |pages=654–60 |year=1999|month=March |pmid=10080465|doi=|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00604-4|accessdate=2011-12-15}}</ref><ref name="pmid8922307">{{cite journal|author=Kaplan BM, Benzuly KH, Kinn JW, Bowers TR, Tilli FV, Grines CL, O'Neill WW, Safian RD|title=Treatment of no-reflow in degenerated saphenous vein graft interventions: comparison of intracoronary verapamil and nitroglycerin|journal=[[Catheterization and Cardiovascular Diagnosis]] |volume=39 |issue=2|pages=113–8 |year=1996 |month=October|pmid=8922307|doi=10.1002/(SICI)1097-0304(199610)39:2<113::AID-CCD1>3.0.CO;2-I |url=|accessdate=2011-12-15}}</ref><ref name="pmid10801755">{{cite journal |author=Marzilli M, Orsini E, Marraccini P, Testa R |title=Beneficial effects of intracoronary adenosine as an adjunct to primary angioplasty in acute myocardial infarction |journal=[[Circulation]] |volume=101 |issue=18|pages=2154–9 |year=2000|month=May |pmid=10801755 |doi=|url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=10801755|accessdate=2011-12-15}}</ref><ref name="pmid15459610">{{cite journal |author=Ono H, Osanai T, Ishizaka H, Hanada H, Kamada T, Onodera H, Fujita N, Sasaki S, Matsunaga T, Okumura K|title=Nicorandil improves cardiac function and clinical outcome in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: role of inhibitory effect on reactive oxygen species formation |journal=[[American Heart Journal]]|volume=148 |issue=4|pages=E15 |year=2004 |month=October|pmid=15459610|doi=10.1016/j.ahj.2004.05.014|url=http://linkinghub.elsevier.com/retrieve/pii/S0002870304002625|accessdate=2011-12-15}}</ref><ref name="pmid8205658">{{cite journal |author=Piana RN, Paik GY, Moscucci M, Cohen DJ, Gibson CM, Kugelmass AD, Carrozza JP, Kuntz RE, Baim DS|title=Incidence and treatment of 'no-reflow' after percutaneous coronary intervention |journal=[[Circulation]]|volume=89|issue=6|pages=2514–8 |year=1994 |month=June |pmid=8205658 |doi=|url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8205658|accessdate=2011-12-15}}</ref><ref name="pmid15936605">{{cite journal |author=Ross AM, Gibbons RJ, Stone GW, Kloner RA, Alexander RW |title=A randomized, double-blinded, placebo-controlled multicenter trial of adenosine as an adjunct to reperfusion in the treatment of acute myocardial infarction (AMISTAD-II) |journal=[[Journal of the American College of Cardiology]]|volume=45|issue=11|pages=1775–80 |year=2005 |month=June|pmid=15936605|doi=10.1016/j.jacc.2005.02.061|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(05)00536-X|accessdate=2011-12-15}}</ref><ref name="pmid11108667">{{cite journal |author=Sdringola S, Assali A, Ghani M, Yepes A, Rosales O, Schroth GW, Fujise K, Anderson HV, Smalling RW|title=Adenosine use during aortocoronary vein graft interventions reverses but does not prevent the slow-no reflow phenomenon|journal=[[Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions]]|volume=51 |issue=4 |pages=394–9 |year=2000|month=December |pmid=11108667|doi=|url=http://dx.doi.org/10.1002/1522-726X(200012)51:4<394::AID-CCD4>3.0.CO;2-G|accessdate=2011-12-15}}</ref><ref name="pmid17985384">{{cite journal |author=Stoel MG, Marques KM, de Cock CC, Bronzwaer JG, von Birgelen C, Zijlstra F |title=High dose adenosine for suboptimal myocardial reperfusion after primary PCI: A randomized placebo-controlled pilot study|journal=[[Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions]] |volume=71 |issue=3 |pages=283–9|year=2008 |month=February|pmid=17985384 |doi=10.1002/ccd.21334|url=http://dx.doi.org/10.1002/ccd.21334|accessdate=2011-12-15}}</ref><ref name="pmid12455077">{{cite journal |author=Werner GS, Lang K, Kuehnert H, Figulla HR |title=Intracoronary verapamil for reversal of no-reflow during coronary angioplasty for acute myocardial infarction|journal=[[Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions]]|volume=57|issue=4 |pages=444–51 |year=2002 |month=December |pmid=12455077|doi=10.1002/ccd.10375|url=http://dx.doi.org/10.1002/ccd.10375|accessdate=2011-12-15}}</ref><ref name="pmid7717298">{{cite journal|author=Weyrens FJ, Mooney J, Lesser J, Mooney MR|title=Intracoronary diltiazem for microvascular spasm after interventional therapy|journal=[[The American Journal of Cardiology]] |volume=75 |issue=12|pages=849–50 |year=1995 |month=April|pmid=7717298 |doi=|url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(99)80430-5|accessdate=2011-12-15}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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