No Reflow and Slow Flow

Revision as of 13:47, 24 August 2010 by Elord (talk | contribs) (New page: {{SI}} {{WikiDoc Cardiology Network Infobox}} {{CMG}}<br/> '''Associate Editors-In-Chief:''' Jennifer Giuseffi, M.D.; David M. Leder, M.D. ==Background== The no reflow, or slow flow, ...)
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Jennifer Giuseffi, M.D.; David M. Leder, M.D.

Background

The no reflow, or slow flow, phenomenon refers to inadequate myocardial perfusion with evidence of persistent myocardial ischemia of a target vessel following thrombolysis or percutaneous coronary intervention (PCI) without angiographic evidence of mechanical obstruction.

Prevalence

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 saphenous vein grafts (SVG) or thrombus containing lesions as well as during the use of rotational atherectomy.

Associations

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.

Mechanism

The primary mechanism is micro-embolization of either plaque debris or thrombotic material to the distal micro-vasculature following balloon inflation or stent deployment. Another possible additional mechanism is arteriole vasospasm secondary to vasoactive agents, i.e. serotonin, adenosine diphosphate, thromboxane A2, released by the embolized platelet-rich atheromatous material. Other factors that may contribute as well include microvascular plugging with platelets or leukocytes, endothelial swelling, tissue edema compressing vasculature, oxidative stress and inflammation.

Clinical Implications

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.

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.

Goals of Treatment

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.

Cost Effectiveness of No Reflow and Slow Flow

| group5 = Clinical Trials Involving No Reflow and Slow Flow | list5 = Ongoing Trials on No Reflow and Slow Flow at Clinical Trials.govTrial results on No Reflow and Slow FlowClinical Trials on No Reflow and Slow Flow at Google


| group6 = Guidelines / Policies / Government Resources (FDA/CDC) Regarding No Reflow and Slow Flow | list6 = US National Guidelines Clearinghouse on No Reflow and Slow FlowNICE Guidance on No Reflow and Slow FlowNHS PRODIGY GuidanceFDA on No Reflow and Slow FlowCDC on No Reflow and Slow Flow


| group7 = Textbook Information on No Reflow and Slow Flow | list7 = Books and Textbook Information on No Reflow and Slow Flow


| group8 = Pharmacology Resources on No Reflow and Slow Flow | list8 = AND (Dose)}} Dosing of No Reflow and Slow FlowAND (drug interactions)}} Drug interactions with No Reflow and Slow FlowAND (side effects)}} Side effects of No Reflow and Slow FlowAND (Allergy)}} Allergic reactions to No Reflow and Slow FlowAND (overdose)}} Overdose information on No Reflow and Slow FlowAND (carcinogenicity)}} Carcinogenicity information on No Reflow and Slow FlowAND (pregnancy)}} No Reflow and Slow Flow in pregnancyAND (pharmacokinetics)}} Pharmacokinetics of No Reflow and Slow Flow


| group9 = Genetics, Pharmacogenomics, and Proteinomics of No Reflow and Slow Flow | list9 = AND (pharmacogenomics)}} Genetics of No Reflow and Slow FlowAND (pharmacogenomics)}} Pharmacogenomics of No Reflow and Slow FlowAND (proteomics)}} Proteomics of No Reflow and Slow Flow


| group10 = Newstories on No Reflow and Slow Flow | list10 = No Reflow and Slow Flow in the newsBe alerted to news on No Reflow and Slow FlowNews trends on No Reflow and Slow Flow


| group11 = Commentary on No Reflow and Slow Flow | list11 = Blogs on No Reflow and Slow Flow

| group12 = Patient Resources on No Reflow and Slow Flow | list12 = Patient resources on No Reflow and Slow FlowDiscussion groups on No Reflow and Slow FlowPatient Handouts on No Reflow and Slow FlowDirections to Hospitals Treating No Reflow and Slow FlowRisk calculators and risk factors for No Reflow and Slow Flow


| group13 = Healthcare Provider Resources on No Reflow and Slow Flow | list13 = Symptoms of No Reflow and Slow FlowCauses & Risk Factors for No Reflow and Slow FlowDiagnostic studies for No Reflow and Slow FlowTreatment of No Reflow and Slow Flow

| group14 = Continuing Medical Education (CME) Programs on No Reflow and Slow Flow | list14 = CME Programs on No Reflow and Slow Flow

| group15 = International Resources on No Reflow and Slow Flow | list15 = No Reflow and Slow Flow en EspanolNo Reflow and Slow Flow en Francais

| group16 = Business Resources on No Reflow and Slow Flow | list16 = No Reflow and Slow Flow in the MarketplacePatents on No Reflow and Slow Flow

| group17 = Informatics Resources on No Reflow and Slow Flow | list17 = List of terms related to No Reflow and Slow Flow


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