No-reflow phenomenon prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Jennifer Giuseffi, M.D.; David M. Leder, M.D.; Ayokunle Olubaniyi, M.B,B.S [2]

Overview

Prevention

Thrombectomy

This procedure is usually done to improve perfusion in STEMI patients before they undergo PCI. It can be done using either a manual thrombus aspiration device or a mechanical thrombectomy device, with the manual device having an edge over the mechanical device in some studies. A meta-analysis study proved that among patients with AMI treated with PCI, the use of manual thrombectomy device is associated with better epicardial and myocardial perfusion, less distal embolization and significant reduction in 30-day mortality.[1] 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.

Distal Embolic Protection Devices

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.

Direct Stenting

When intervening on high-risk lesions, limit the amount of instrumentation within the target vessel, which includes minimizing overaggressive balloon orstent expansion (i.e., without predilation). This has been with a significant reduction in microvascular injury.[2] In patients undergoing rotational atherectomy, shorter runs, slower speeds and smaller initial burr size with small step-wise increases in burr size should be employed to help prevent no reflow.

Systemic GP IIb/IIIa inhibitors

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.

Use of Vasodilators

Intracoronary administration of adenosine, verapamil, streptokinase, or abciximab have been used during PCI to reduce reperfusion injury and improve myocardial perfusion. In addition, a cocktail of heparin, nitroglycerin and 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.

Chronic Statin Therapy

In a study, intracoronary myocardial contrast echocardiography was performed in selected patients with acute myocardial infarction undergoing PCI. It was observed that there was a reduction in the incidence of no-reflow in those pre-treated with statins.[3] Another 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.

ACCF/AHA/SCAI 2011 Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[4]

No-Reflow Pharmacological Therapies (DO NOT EDIT)[4]

Class IIa
"1. Administration of an intracoronary vasodilator (adenosine, calcium channel blocker, or nitroprusside) is reasonable to treat PCI-related no-reflow that occurs during primary or elective PCI.[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] (Level of Evidence: B)"


References

  1. De Luca, G.; Dudek, D.; Sardella, G.; Marino, P.; Chevalier, B.; Zijlstra, F. (2008). "Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized trials.". Eur Heart J. 29 (24): 3002–10. PMID 18775918. doi:10.1093/eurheartj/ehn389. 
  2. Loubeyre, C.; Morice, MC.; Lefèvre, T.; Piéchaud, JF.; Louvard, Y.; Dumas, P. (2002). "A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction.". J Am Coll Cardiol. 39 (1): 15–21. PMID 11755281. 
  3. Iwakura, K.; Ito, H.; Kawano, S.; Okamura, A.; Kurotobi, T.; Date, M.; Inoue, K.; Fujii, K. (2006). "Chronic pre-treatment of statins is associated with the reduction of the no-reflow phenomenon in the patients with reperfused acute myocardial infarction.". Eur Heart J. 27 (5): 534–9. PMID 16401674. doi:10.1093/eurheartj/ehi715. 
  4. 4.0 4.1 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 (2011). "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" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. PMID 22070837. doi:10.1016/j.jacc.2011.08.006. Retrieved 2011-12-08. 
  5. Amit G, Cafri C, Yaroslavtsev S, Fuchs S, Paltiel O, Abu-Ful A, Weinstein JM, Wolak A, Ilia R, Zahger D (2006). "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". American Heart Journal. 152 (5): 887.e9–14. PMID 17070151. doi:10.1016/j.ahj.2006.05.010. Retrieved 2011-12-15. 
  6. Assali AR, Sdringola S, Ghani M, Denkats AE, Yepes A, Hanna GP, Schroth G, Fujise K, Anderson HV, Smalling RW, Rosales OR (2000). <27::AID-CCD7>3.0.CO;2-0 "Intracoronary adenosine administered during percutaneous intervention in acute myocardial infarction and reduction in the incidence of "no reflow" phenomenon". Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions. 51 (1): 27–31; discussion 32. PMID 10973014. Retrieved 2011-12-15. 
  7. Barcin C, Denktas AE, Lennon RJ, Hammes L, Higano ST, Holmes DR, Garratt KN, Lerman A (2004). "Comparison of combination therapy of adenosine and nitroprusside with adenosine alone in the treatment of angiographic no-reflow phenomenon". Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions. 61 (4): 484–91. PMID 15065143. doi:10.1002/ccd.20010. Retrieved 2011-12-15. 
  8. Fischell TA, Haller S, Pulukurthy S, Virk IS (2008). "Nicardipine and adenosine "flush cocktail" to prevent no-reflow during rotational atherectomy". Cardiovascular Revascularization Medicine : Including Molecular Interventions. 9 (4): 224–8. PMID 18928946. doi:10.1016/j.carrev.2008.03.002. Retrieved 2011-12-15. 
  9. Hillegass WB, Dean NA, Liao L, Rhinehart RG, Myers PR (2001). "Treatment of no-reflow and impaired flow with the nitric oxide donor nitroprusside following percutaneous coronary interventions: initial human clinical experience". Journal of the American College of Cardiology. 37 (5): 1335–43. PMID 11300444. Retrieved 2011-12-15. 
  10. Huang RI, Patel P, Walinsky P, Fischman DL, Ogilby JD, Awar M, Frankil C, Savage MP (2006). "Efficacy of intracoronary nicardipine in the treatment of no-reflow during percutaneous coronary intervention". Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions. 68 (5): 671–6. PMID 17034064. doi:10.1002/ccd.20885. Retrieved 2011-12-15. 
  11. Ito H, Taniyama Y, Iwakura K, Nishikawa N, Masuyama T, Kuzuya T, Hori M, Higashino Y, Fujii K, Minamino T (1999). "Intravenous nicorandil can preserve microvascular integrity and myocardial viability in patients with reperfused anterior wall myocardial infarction". Journal of the American College of Cardiology. 33 (3): 654–60. PMID 10080465. Retrieved 2011-12-15. 
  12. Kaplan BM, Benzuly KH, Kinn JW, Bowers TR, Tilli FV, Grines CL, O'Neill WW, Safian RD (1996). "Treatment of no-reflow in degenerated saphenous vein graft interventions: comparison of intracoronary verapamil and nitroglycerin". Catheterization and Cardiovascular Diagnosis. 39 (2): 113–8. PMID 8922307. doi:10.1002/(SICI)1097-0304(199610)39:2<113::AID-CCD1>3.0.CO;2-I. 
  13. Marzilli M, Orsini E, Marraccini P, Testa R (2000). "Beneficial effects of intracoronary adenosine as an adjunct to primary angioplasty in acute myocardial infarction". Circulation. 101 (18): 2154–9. PMID 10801755. Retrieved 2011-12-15. 
  14. Ono H, Osanai T, Ishizaka H, Hanada H, Kamada T, Onodera H, Fujita N, Sasaki S, Matsunaga T, Okumura K (2004). "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". American Heart Journal. 148 (4): E15. PMID 15459610. doi:10.1016/j.ahj.2004.05.014. Retrieved 2011-12-15. 
  15. Piana RN, Paik GY, Moscucci M, Cohen DJ, Gibson CM, Kugelmass AD, Carrozza JP, Kuntz RE, Baim DS (1994). "Incidence and treatment of 'no-reflow' after percutaneous coronary intervention". Circulation. 89 (6): 2514–8. PMID 8205658. Retrieved 2011-12-15. 
  16. Ross AM, Gibbons RJ, Stone GW, Kloner RA, Alexander RW (2005). "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 of the American College of Cardiology. 45 (11): 1775–80. PMID 15936605. doi:10.1016/j.jacc.2005.02.061. Retrieved 2011-12-15. 
  17. Sdringola S, Assali A, Ghani M, Yepes A, Rosales O, Schroth GW, Fujise K, Anderson HV, Smalling RW (2000). <394::AID-CCD4>3.0.CO;2-G "Adenosine use during aortocoronary vein graft interventions reverses but does not prevent the slow-no reflow phenomenon". Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions. 51 (4): 394–9. PMID 11108667. Retrieved 2011-12-15. 
  18. Stoel MG, Marques KM, de Cock CC, Bronzwaer JG, von Birgelen C, Zijlstra F (2008). "High dose adenosine for suboptimal myocardial reperfusion after primary PCI: A randomized placebo-controlled pilot study". Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions. 71 (3): 283–9. PMID 17985384. doi:10.1002/ccd.21334. Retrieved 2011-12-15. 
  19. Werner GS, Lang K, Kuehnert H, Figulla HR (2002). "Intracoronary verapamil for reversal of no-reflow during coronary angioplasty for acute myocardial infarction". Catheterization and Cardiovascular Interventions :Official Journal of the Society for Cardiac Angiography & Interventions. 57 (4): 444–51. PMID 12455077. doi:10.1002/ccd.10375. Retrieved 2011-12-15. 
  20. Weyrens FJ, Mooney J, Lesser J, Mooney MR (1995). "Intracoronary diltiazem for microvascular spasm after interventional therapy". The American Journal of Cardiology. 75 (12): 849–50. PMID 7717298. Retrieved 2011-12-15. 

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