No reflow phenomenon in CAD patients after percutaneous coronary intervention: A prospective hospital based observational study

The present study assessed incidence, risk factors, in-hospital and short-term outcomes associated with no-reflow in patients undergoing percutaneous coronary intervention (PCI) in STEMI, NSTEMI, unstable angina and stable angina. Out of 449 patients, 42 (9.3%) developed no-reflow. Hypertension, dyslipidemia, obesity and smoking were significant risk factors. There was significant association of no-reflow with left main disease, multiple stents, target lesion length_x0001_ 20 mm and higher thrombus grade. Interestingly, 93 patients (23.4%) of normal flow had myocardial perfusion grade (MPG) of 0/1 with mortality in 9 (10%) patients. No-reflow is associated with poor in-hospital and short-term outcomes with higher incidence of death, cardiogenic shock, heart failure and MACE. Knowledge of risk factors of no-reflow portends a more meticulous approach to improve final outcomes. MPG could be better predictor of outcomes in these patients.

Avaliação do Nível de Fluxo Coronário com MOTS-C em Pacientes com IAMCSST Submetidos à ICP Primária / Evaluation of Coronary Flow Level with Mots-C in Patients with STEMI Undergoing Primary PCI

Resumo Fundamentos Os efeitos protetores da fase de leitura aberta mitocondrial do 12S rRNA-c (MOTS-C) em doenças cardiovasculares foram demonstrados em vários estudos. Entretanto, há pouca documentação da relação entre MOTS-C e fluxo sanguíneo coronariano no infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Objetivo Nosso objetivo foi investigar o papel do MOTS-C, que é conhecido por ter propriedades citoprotetoras na patogênese do fenômeno de no-reflow, comparando a taxa de fluxo coronariano e os níveis de MOTS-C em pacientes com IAMCSST submetidos à ICP primária. Métodos 52 pacientes com IAMCSST e 42 pacientes sem estenose >50% nas artérias coronárias foram incluídos no estudo. O grupo IAMCSST foi dividido em dois grupos de acordo com o grau de fluxo TIMI (do inglês Thrombolysis In Myocardial Infarction) pós-ICP: (i) No-reflow: graus 0, 1 e 2 e (ii) grau 3 (sucesso angiográfico). Um valor de p <0,05 foi considerado significante. Resultados Os níveis de MOTS-C foram significativamente menores no grupo IAMCSST em comparação ao grupo controle (91,9 ± 8,9 pg/mL vs. 171,8±12,5 pg/mL, p<0,001). Além disso, a análise da curva Receiver Operating Characteristics (ROC) indicou que os níveis séricos de MOTS-C tinham um valor diagnóstico na previsão de no-reflow (Área sob a curva ROC [AUC]: 0,95, IC95%: 0,856-0,993, p < 0,001). Um valor de MOTS-C ≥84,15 pg/mL medido na hospitalização mostrou ter sensibilidade de 95,3% e especificidade de 88,9% na previsão de no-reflow. Conclusão MOTS-C é um preditor forte e independente de no-reflow e eventos cardiovasculares adversos maiores (ECAM) intra-hospitalar em pacientes com IAMCSST. Também foi observado que baixos níveis de MOTS-C podem ser um importante marcador prognóstico e podem ter um papel na patogênese do IAMCSST.

Abstract Background The protective effects of mitochondrial open reading frame of the 12S rRNA-c (MOTS-C) on cardiovascular diseases have been shown in numerous studies. However, there is little documentation of the relationship between MOTS-C and coronary blood flow in ST-segment elevation myocardial infarction (STEMI). Objective We aimed to investigate the role of MOTS-C, which is known to have cytoprotective properties in the pathogenesis of the no-reflow phenomenon, by comparing the coronary flow rate and MOTS-C levels in patients with STEMI submitted to primary PCI. Methods 52 patients with STEMI and 42 patients without stenosis >50% in the coronary arteries were included in the study. The STEMI group was divided into two groups according to post-PCI TIMI (Thrombolysis In Myocardial Infarction) flow grade:(i) No-reflow: grade 0, 1, and 2 and (ii) grade 3(angiographic success). A p value of <0.05 was considered significant. Results MOTS-C levels were significantly lower in the STEMI group compared to the control group (91.9 ± 8.9 pg/mL vs. 171.8±12.5 pg/mL, p<0.001). In addition, the Receiver Operating Characteristics (ROC) curve analysis indicated that serum MOTS-C levels had a diagnostic value in predicting no-reflow (Area Under the ROC curve [AUC]:0.95, 95% CI:0.856-0.993, p<0.001). A MOTS-C ≥84.15 pg/mL measured at admission was shown to have 95.3% sensitivity and 88.9% specificity in predicting no-reflow. Conclusion MOTS-C is a strong and independent predictor of no-reflow and in-hospital MACE in patients with STEMI. It was also noted that low MOTS-C levels may be an important prognostic marker of and may have a role in the pathogenesis of STEMI.

Complicações em Serviços de Hemodinâmica ­ como agir / Complications in Cath Lab ­ how to bail out

Vários fatores, incluindo intervenções terapêuticas aprimoradas e tecnologias avançadas, levaram a melhores desfechos clínicos nas intervenções coronárias percutâneas complexas. No entanto, ainda podem ocorrer complicações capazes de impactar negativamente na sobrevida do paciente e nos custos de saúde. O risco dessas complicações pode ser reduzido, por meio de operadores experientes e procedimentos preventivos. Este artigo discute uma série de casos de cinco pacientes com problemas específicos relacionados aos procedimentos, como perfuração coronária, dissecções, fechamento abrupto das coronárias e fenômeno de no-reflow.

Various factors, including improved therapeutic interventions and advanced technologies, have led to better clinical outcomes for complex percutaneous coronary interventions. However, complications can still occur and have a negative impact on patient survival and healthcare costs. The risk of these complications can be reduced through experienced operators and preventative procedures. This article discusses a case series of five patients with specific periprocedural issues, such as coronary perforation, dissections, abrupt closure of the coronaries, and no-reflow phenomenon.

Predictores de fenómeno de no reflujo en infarto agudo del miocardio con elevación del segmento ST / Predictors in no-reflow phenomenon in acute myocardial infarction with ST-segment elevation

Resumen Antecedentes: El fenómeno de «no reflujo¼ (NR) es una de las complicaciones más temidas tras una intervención coronaria percutánea (ICP) en el tratamiento del infarto de miocardio con elevación del segmento ST (IAMCEST) por su elevada morbimortalidad. Objetivo: Describir los factores predictores para el fenómeno de NR en un grupo de sujetos con IAMCEST tratados con ICP. Método: Se estudiaron 103 casos de IAMCEST a los que se les realizó una ICP. Los sujetos se dividieron de acuerdo con la presencia del fenómeno de NR. Se estudió mediante un análisis multivariante la edad, el sexo, presencia de comorbilidades, el peso y otros parámetros clínicos y de laboratorio como predictores del fenómeno de NR. Resultados: En este estudio, el análisis con regresión logística identificó como factores independientes para el desarrollo de fenómeno de NR el flujo TIMI basal ≤ 2 (razón de momios [OR]6.03; intervalo de confianza del 95% [IC 95%]: 0.9-11.8; p = 0.04), estadio enfermedad renal según KDIGO (Kidney Disease Improving Global Outcomes) ≥ 3 (OR 3.49; IC 95%: 1.2-2.6; p = 0.02) y nivel de glucosa ≥ 180 mg/dl(OR 2.61; IC 95%: 1.0-2.4; p = 0.04). Conclusiones: El fenómeno de NR sigue siendo un reto para la morbimortalidad a corto y a largo plazo en el IAMCEST. Los factores identificados pueden ser utilizados para la estratificación de los casos con IAMCEST y riesgo de fenómeno de NR previo a la ICP.

Abstract Background: No-reflow (NR) phenomenon is one of the most feared complications after percutaneous coronary intervention (PCI) in the treatment of ST-segment elevation myocardial infarction (STEMI) due to its high morbidity and mortality. Objective: To describe the predictive factors for NR phenomenon in a group of subjects with STEMI treated with PCI. Method: One hundred and three cases of STEMI who underwent PCI. The subjects were divided according to the presence of NR phenomenon. In a multivariate analysis age, gender, comorbidities, weight, and other clinical and laboratory parameters were studied as predictors of NR phenomenon were studied. Results: In this study, logistic regression analysis identified as independent factors for the development of NR phenomenon baseline TIMI flow ≤ 2 (OR 6.03; 95% CI, 0.9 to 11.8; p = 0.04), ER KDIGO ≥ 3 (OR OR 2.61; 95% CI, 1.0 to 2.4; p = 0.04). Conclusions: NR phenomenon continues to be a challenge for short and long-term morbidity and mortality in STEMI. The identified factors can be used for the stratification of cases with STEMI and risk of NR phenomenon prior to PCI.

Pathophysiological mechanisms of futile recanalization following endovascular therapy for acute ischemic stroke due to large vessel occlusion and potential targeted therapeutic strategy / 中华神经科杂志

Endovascular therapy is the standard treatment for acute ischemic stroke due to large vessel occlusion. However, an increasing number of studies have demonstrated that about half of patients had poor functional recovery despite successful recanalization, namely futile recanalization. Previous studies suggested that tissue no-reflow (lack of reperfusion despite recanalized large vessel), early re-occlusion, poor collateral status, hemorrhagic transformation, impaired cerebral autoregulation and large hypoperfusion volume may all contribute to futile recanalization. Targeted treatment strategies for these mechanisms have been attempted in pre-clinical researches but failed to translate into clinical practices. This review aimed to summarize the mechanisms of futile recanalization and potential targeted treatment strategies, particularly focus on the no-reflow phenomenon and its mechanisms, clinical evaluation, and treatment approaches, hoping to promote translational research and improve the status of stroke treatment.

Comparação dos Resultados entre os Fenômenos de No-Reflow e Slow-Flow Coronariano em Pacientes sem IAMSSST / Comparison of the Outcomes between Coronary No-Reflow and Slow-Flow Phenomenon in Non-STEMI Patients

Resumo Fundamento: Os fenômenos de slow-flow (CSFP) e no-reflow coronariano (CNP) estão associados a um risco aumentado de eventos cardiovasculares adversos maiores (ECAM). Objetivos: Este estudo teve como objetivo avaliar e comparar os resultados do seguimento clínico de um ano entre pacientes com CNP e CSFP submetidos a intervenções coronárias percutâneas (ICP) em infarto agudo do miocárdio sem supradesnivelamento do segmento ST (IAMSSST). Métodos: Este estudo incluiu um total de 858 pacientes com diagnóstico de IAMSSST e submetidos a ICP nas 24 horas desde o início dos sintomas. Os pacientes foram divididos em dois grupos, o grupo CSFP (n = 221) e o grupo CNP (n = 25), considerando as características angiográficas do fluxo da trombólise no infarto do miocárdio (TIMI) e na artéria relacionada ao infarto. Os pacientes tiveram um seguimento de um ano. Um valor de p <0,05 foi considerado significativo. Resultados: O CNP foi observado em 2,91% e o CSFP em 25,75% dos pacientes. Os desfechos clínicos analisaram que a incidência de acidente vascular cerebral (AVC) foi significativamente maior no grupo CNP do que no grupo CSFP (6 (24%) vs. 6 (2,70%), p <0,001) e a de ECAM foi significativamente maior no grupo CNP do que no grupo CSFP (11 (44%) vs. 51 (23,10%), p = 0,022). A análise de regressão logística condicional forward demonstrou que o índice de massa corporal (IMC) (OR = 1,11, IC95%: 1,00-1,24, p = 0,038) e frequência cardíaca (FC) basal (OR = 0,923, IC 95%: 0,88-0,96, p <0,001) foram os preditores independentes de CNP no IAMSSST. Conclusões: Pacientes com CNP têm piores resultados clínicos e um maior risco de AVC em comparação com pacientes com CSFP no IAMSSST.

Abstract Background: Coronary slow-flow phenomenon (CSFP) and coronary no-reflow phenomenon (CNP) are associated with increased risk of major cardiovascular adverse events (MACE). Objectives: This study aimed to evaluate and compare the one-year clinical follow-up outcomes among patients with CNP and CSFP who underwent percutaneous coronary interventions (PCI) in non-ST elevation myocardial infarction (NSTEMI). Methods: This study included a total of 858 patients who were diagnosed with NSTEMI and underwent PCI within 24 h of symptom onset. The patients were divided into two groups, the CSFP group (n=221) and the CNP group (n=25), regarding the angiographic characteristics of thrombolysis in myocardial infarction (TIMI) flow of the infarct-related artery. Patients were followed for one-year. A p-value of <0.05 was considered significant. Results: CNP was observed in 2.91%, and CSFP was observed in 25.75% of the patients. Clinical endpoints analyzed that stroke was significantly higher in the CNP group than in the CSFP group (6 (24%) vs. 6 (2.70%), p<0.001) and MACE was significantly higher in the CNP group than in the CSFP group (11 (44%) vs. 51 (23.10%), p=0.022). Forward conditional logistic regression analysis demonstrated that body mass index (BMI) (OR=1.11, 95%CI: 1.00-1.24, p=0.038) and baseline heart rate (HR) (OR=0.923, 95%CI: 0.88-0.96, p<0.001) were the independent predictors of CNP in NSTEMI. Conclusion: CNP patients have worse clinical outcomes and a higher risk of stroke compared with CSFP patients in NSTEMI. (Arq Bras Cardiol. 2021; 116(5):856-864)

The predictive value of D-dimer combined with activated partial thromboplastin time for slow / no reflow during PCI in patients with acute coronary syndrome / 中国医师杂志

Objective:To analyze the predictive value of D-dimer combined with activated partial thromboplastin time (APTT) for slow / no reflow in patients with acute coronary syndrome (ACS) during percutaneous coronary intervention(PCI).Methods:From June 2017 to June 2019, 316 cases of patients with ACS who were to undergo PCI in Guigang People′s Hospital were selected as the study objects. The patients were divided into slow / no reflow group (SNR) and normal blood flow group (CON) according to the blood flow grading of thrombolysis in myocardial infarction (TIMI) during the operation. The differences of D-dimer and APTT between the two groups before operation were compared, and the predictive value of D-dimer combined with APTT for SNR was analyzed.Results:According to TIMI blood flow grading, all the patients were divided into SNR group ( n=71, 22.47%) and CON group ( n=245, 77.53%). The level of D-dimer in SNR group was significantly higher than that in CON group, while APTT was significantly lower than that in CON group ( P<0.05). Logistic regression analysis showed that D-dimer elevation ( OR=1.011, 95% CI: 1.008-1.015, P<0.001) was an independent risk factor of slow / no reflow in PCI for ACS patients, while APTT elevation ( OR=0.868, 95% CI: 0.818-0.921, P<0.001) was a protective factor. The D-dimer and APTT predicted that the area under receiver operating characteristic (ROC) curve of slow / no reflow in PCI were 0.814 and 0.738 respectively. The area under ROC curve of combined detection of D-dimer and APTT increased to 0.869, and the sensitivity and specificity were 87.3% and 75.1% respectively ( P<0.001). Conclusions:The D-dimer and APTT have a high predictive value of slow / no reflow during PCI in ACS patients. The combined detection of the two is helpful to identify the occurrence of slow / no reflow in PCI.

Relationship between high mobility group protein box-1 level in peripheral blood and no-reflow in patients with acute myocardial infarction after interventional therapy / 中国基层医药

Objective:To investigate the relationship between high mobility group protein box-1 (HMGB1) level in peripheral blood and no-reflow in patients with acute myocardial infarction after interventional therapy.Methods:120 patients with acute myocardial infarction patients who received interventional treatment in Liuzhou People's Hospital, China between October 2019 and October 2020 were included in this study. They were divided into normal blood flow group ( n = 78) and no-reflow group ( n = 42) according to the situation of coronary reflow after interventional treatment. The clinical data and laboratory test results were compared between the two groups. The level of HMGB1 in peripheral blood was detected using enzyme-linked immunosorbent assay and compared between the two groups. The diagnostic value of HMGB1 in no reflow was analyzed by the receiver operating characteristic (ROC) curve. Results:There were no significant differences in age, gender, history of hypertension, history of smoking, history of coronary heart disease, and peak value of creatine kinase MB between no reflow and normal flow groups (all P > 0.05). The number of patients developing diabetes mellitus, the proportion of patients developing lesions of multiple vessels, C-reactive protein level and brain natriuretic peptide level in no-reflow group were significantly higher than those in the normal blood flow group (all P < 0.05). Enzyme-linked immunosorbent assay results revealed that there was significant difference in HMGB1 level between no reflow and normal flow groups [(5.2 ± 0.85) mg/L vs.(3.2 ± 0.9) mg/L, t = -2.38, P = 0.02). The ROC curve was used to compare the diagnostic values of HMGB1, brain natriuretic peptide and C-reactive protein for no reflow. The results showed that the area under the ROC curve values of HMGB1, brain natriuretic peptide and C-reactive protein were 0.746 (0.661-0.830), 0.605 (0.504-0.705) and 0.688 (0.595-0.781), respectively. The area under the ROC curve value of HMGB1 was the highest. Conclusion:The level of HMGB1 is obviously increased in patients with acute myocardial infarction presenting with no reflow, which has a high diagnostic value for no reflow.

Effects of Tirofiban combined with thrombus aspiration on myocardial reperfusion and no-reflow after percutaneous coronary intervention in elderly patients with ST-segment elevation myocardial infarction / 中华老年医学杂志

Objective To investigate the effects of Tirofiban combined with thrombus aspiration on myocardial reperfusion and no-reflow after percutaneous coronary intervention (PCI)in elderly patients with ST-segment elevation myocardial infarction (STEMI).Methods A total of 185 patients with STEMI were randomly divided into a control group(n=93)and a study group(n=92).The control group received direct stenting or percutaneous coronary angioplasty before stent placement.The study group received an intracoronary injection of Tirofiban 10 μg/kg,thrombus aspiration,and then balloon dilatation or direct coronary stenting.Postoperative recovery was compared between the groups,and major adverse cardiovascular events(MACE) were recorded.Results The incidence of no-reflow,the thrombolysis in myocardial infarction,the corrected (TIMI)frame count (CTFC)and the peak of plasma creatine kinase MB isoenzyme(CK MB)were lower in the study group than in the control group[(no reflow,8 cases or 8.7 ％ vs.21cases or 22.6 ％,x2 =6.752,P ＜0.05;CTFC,(26.4±8.7)frame vs.(34.5± 8.2)frame,t =6.517,P＜0.05;CK-MB peak,(114.5±25.7)U/L vs.(226.3 ± 27.6) U/L,t =28.506,P ＜ 0.05].The proportion of patients with descent of ST segment elevation of more than 50％ and the left ventricular ejection fraction(LVEF)were higher in the study group than in the control group[83 cases or 90.2％ vs.72 cases or 77.4％,x2=5.581,P＜0.05;(56.2±8.6) ％ vs.(48.8±10.5)％,t =5.241,P＜0.05].The TIMI grading was better in the study group than in the control group (Z =1.984,P ＜ 0.05).The incidence of mild bleeding during treatment had no significant difference between the study group and the control group(20.7％ or 19 cases vs.15.1％ or 14 cases,x2 =0.99,P =0.32).There was no significant difference in the incidence of MACE events during hospitalization or one-year follow-up between the two groups(x2=2.394,0.452,P ＞ 0.05).Conclusions Tirofiban combined with thrombus aspiration can improve myocardial reperfusion in elderly patients with STEMI after PCI,and has excellent clinical value.

Establishment and evaluation of rat models of myocardial ischemia reperfusion-related no-reflow under non-artificial ventilator / 吉林大学学报(医学版)

Objective: To establish the rat models of myocardial ischemia reperfusion-related no-reflow under non-artificial ventilator, to evaluate the models by morphology, hematological biochemistry and hemorheology, and to lay the foundation for studying the pathogenesis of cardiovascular diseases and evaluating the pharmacodynamics of drugs of cardiovascular diseases. Methods: Fifty healthy female Wistar rats were randomly divided into sham operation group (n=20) and model group (n=30). The myocardial ischemia reperfusion-related no-reflow rat models in model group were induced by ligation of left anterior descending coronary artery for 2 h and another 2 h for reperfusion. The rats in sham group were only threaded and not ligated. The model was evaluated by detecting the area at risk (AAR), area at infarct (AAD, area at no-reflow (AAN) of myocardium, the activities of creatine kinase MB (CK-MB), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) in serum, the whole blood viscosity, the plasma viscosity, the platelet adhesion rate (PAR), the platelet aggregation (PAG) of the rats. Results: Compared with sham operation group, the AAR, AAI, and AAN of myocardium, the activities of CK-MB, LDH, and AST in serum, the whole blood low shear viscosity (20/s), the middle shear viscosity (60/s), the high shear viscosity (120/s), the plasma viscosity, PAR, PAG (1, 3, 5 min) and the maximum platelet aggregation rate (MAPG) of the rats in model group were significantly increased (P<0. 05 or P<0. 01). Conclusion: The rat model of myocardial ischemia reperfusion-related no-reflow under non-artificial ventilator is successfully established. This method is characterized by simple operation, decreased injury to animals, higher stability of model construction, shorter experimental cycle and less cost.

Efficacy and safety of different drugs by balloon catheter injection for no-reflow following percutaneous coronary intervention / 中华全科医师杂志

Objective To evaluate the efficacy and safety of different drugs injected via balloon catheter for no-reflow after percutaneous coronary intervention (PCI) in patients with ST segment elevation myocardial infarction (STEMI).Methods From January 2016 to December 2017,1 280 patients with STEMI were treated in Department of Cardiology,Beijing Luhe Hospital.All patients were underwent PCI and stent implantation in related infarct vessels (IRA).Among 1 280 patients no-reflow occurred in 164 cases (12.81％) during the procedure.No-reflow patients were divided into three study groups according to the order of consultation,who were given verapamil (verapamil group,55 cases),tirofiban (tirofiban group,55 cases) or nitroglycerin (nitroglycerin group,54 cases) by injection through balloon catheter.Coronary blood flow recovery (TIMI grading),myocardial perfusion level TMP grading (TMPG),average dose of drugs (mg) and adverse drug reactions (ADR) were compared among the three groups.Left ventricular ejection fraction (LVEF) and left ventricular end diastolic volume (LVEDV) were evaluated by echocardiography 7 and 30 d after operation.The incidence of major adverse cardiovascular events (MACE) was followed up.Results TIMI-3 ratio in verapamil,tirofiban and nitroglycerin groups was 89.90％ (49/55),91.82％ (45/55) and 61.11％ (33/54),respectively (Hc=13.920,P＜0.05).TMP-3 ratio was 72.73％(40/55) in verapamil group,65.45％ (36/55) in tirofiban group and 50.0％ (27/54) in nitroglycerin group,respectively (Hc=6.230,P＜0.05).During the procedure,one case (1.82％) had slow heart rate and one case (1.82％) had hypotension in verapamil group;three cases 5.56％) had transient hypotension in nitroglycerin group,and there was no significant difference in the incidence of ADR among the three groups (Hc=0.040,P＞0.05).There was no significant difference in LVEF and LVEDV among three groups on the d7 after operation (all P＞0.05).The improvement of LVEF and LVEDV was more significant in verapamil group on d30 after operation (all P＜0.05).One case (1.82％) of heart failure occurred in tirofiban group,three cases of heart failure and one case of recurrent myocardial infarction occurred in nitroglycerin group during six months of follow-up.There was no significant difference in the overall incidence of MACE among the three groups (Hc=0.070,P＞0.05).Conclusion Verapamil can be injected throμgh balloon catheter to restore coronary blood flow rapidly,effectively and safely,and improve left ventricular function in STEMI patients with no-reflux during PCI.

Fenómeno de no reflujo en la angioplastia coronaria: incidencia, características clínico-angiográficas y eficacia del tratamiento / No-reflow phenomenon in coronary angioplasty: incidence, clinical-angiographic characteristics and efficacy of treatment

Resumen: Introducción: el fenómeno de no reflujo (NR) coronario se define como la persistencia de un flujo inadecuado menor a TIMI 3 durante la angioplastia coronaria (ATC), en ausencia de obstáculo macroscópico en las arterias coronarias epicárdicas. Objetivo principal: determinar la incidencia de NR en pacientes tratados con ATC por cualquier indicación. Objetivos secundarios: describir las características clínicas y angiográficas de la población con NR, características del procedimiento de angioplastia, así como el tratamiento y el valor pronóstico del NR. Métodos: estudio observacional, prospectivo, unicéntrico, sobre el total de ATC realizadas en un centro de cardiología intervencionista entre octubre de 2016 y enero de 2017, excluyendo la reestenosis intrastent y la enfermedad de injertos venosos. Se definieron dos grupos: control (flujo normal) y con fenómeno de NR. Se analizaron variables clínicas, angiográficas, terapéuticas y pronósticas. Resultados: se incluyó un total de 322 pacientes, 291 control y 31 NR. La incidencia de NR fue de 9,6%, presentándose en 20,7% de los síndromes coronarios agudos con elevación de ST (SCAcST), en 6,3% de los síndromes coronarios agudos sin elevación de ST (SCAsST) y en 3% de las anginas estables. La adenosina a dosis altas fue el tratamiento más utilizado. Se comprobó una mejoría significativa del flujo coronario evaluado por TIMI Frame Count asociado al tratamiento instituido (39,4±1,6 pretratamiento vs 21,9±1,2 postratamiento, p<0,001). A tres meses, en los pacientes con NR vesus control se observó una mayor incidencia de ángor (6,6% vs 1,1% respectivamente, p=0,001), nueva coronariografía (10% vs 1,1%, p=0,017) y nueva ATC (19% vs 1,1%, p=0,009). Conclusiones: la incidencia de NR en pacientes sometidos a ATC fue de 9,6%, presentándose más frecuentemente en el SCAcST. La adenosina intracoronaria a dosis altas fue el tratamiento más frecuentemente instituido y fue eficaz para mejorar significativamente el flujo coronario.

Summary: Introduction: no-reflow phenomenon is defined as persistence of inadequate flow less than TIMI 3 during coronary angioplasty in the absence of an obstacle in epicardial coronary arteries. Primary endpoint: to determine the incidence of no-reflow in patients treated with coronary angioplasty performed for any indication. Secondary endpoints: to describe the clinical and angiographic characteristics, procedural characteristics, treatment and prognostic value of no-reflow phenomenon. Methods: this is an observational, prospective and unicentric trial including all coronary angioplasties performed in an interventional Cardiology center between October 2016 and January 2017, excluding instent reestenosis and coronary vein grafts disease. Two groups were defined: control (normal coronary flow) and no-reflow phenomenon. Clinical, angiographic and prognostic variables were analyzed. Results: 322 patients were included, 291 control and 31 no-reflow. No-reflow incidence was 9.6%, occurring in 20.7% of acute coronary syndromes with ST segment elevation, 6.3% in non-ST segment elevation syndromes and 3% in stable coronary artery disease. High dose adenosine was the most frequently used agent for no-reflow treatment. No-reflow treatment was associated with a significant improvement in coronary flow measured by TIMI Frame Count (39.4±1.6 pretreatment vs 21.9±1.2 postreatment, p<0.001). At 3 month follow up, no-reflow patients vs control had a higher incidence of angina pectoris (6.6% vs 1.1% respectively, p=0.001), coronary angiography (10% vs 1.1%, p=0.017) and coronary angioplasty (19% vs 1.1%, p=0.009). Conclusions: no-reflow incidence in patients treated with coronary angioplasty was 9.6%, occurring more frequently in ST segment elevation syndromes. High dose adenosine was the most frequently used agent for no-reflow treatment and significantly improved coronary flow.

Utilidad de la angiografía intracoronaria con microcatéter para evitar fenómeno de no reflujo en la angioplastia primaria / Utility of the intracoronary angiography with microcatheter to avoid no reflow phenomenon in primary angioplasty

Resumen Introducción La oclusión coronaria aguda, asociada a alta tasa de morbimortalidad en el infarto agudo del miocardio con elevación del segmento ST (IAMCEST), representa un desafío para el intervencionista cuando desconoce el importe de carga de trombo y las características distales a la oclusión (obstrucción microvascular (OMV), estenosis distal) que complican la angioplastia primaria (ACTP) y el fenómeno de no reflujo (FNR), el cual tiene una incidencia reportada de 20 a 40%. Objetivos Evaluar la eficacia de la angiografía distal con microcatéter al orientar una estrategia terapéutica individualizada con la finalidad de prevenir el FNR en oclusión coronaria aguda por IAMCEST en ACTP. Material y métodos Se incluyeron 70 pacientes con IAMCEST. Se realizó angiografía con microcatéter distal a la obstrucción y se eligió la estrategia terapéutica en la angioplastia de conformidad con hallazgos: estenosis, carga de trombo y OMV. Posteriormente se evaluó la incidencia de FNR al finalizar la ACTP. Resultados Reporte de 70 pacientes, la mayoría hombres (80%), clase Killip-Kimball I (95%), con afección de la arteria coronaria derecha en 57% de ellos y de la descendente anterior en 37%. Trombo distal presente en 47% de los pacientes estudiados, se observó en 21% de los casos que la longitud de obstrucción fue mayor de 30 mm, disección de las arterias también en 21%, OMV presente en 41% y 25% con estenosis distal. Estrategias terapéuticas utilizadas: se aplicó stent con fármaco en 81% de los pacientes, balón largo en 93% y trombolítico en 30%. Se observó una incidencia del FNR de 18.6%. Conclusiones En IAMCEST la técnica propuesta disminuye el FNR en comparación con lo reportado. La obstrucción > 30 mm es factor independiente de FNR, por lo que en estos casos recomendamos el uso de esta técnica y balón largo.

Abstract Introduction The acute coronary occlusion associated with a high valuation of morbimortalidad in the acute infarction of the myocardium with elevation of the ST segment (STEMI), represents a challenge for the interventionist, due the unknown amount of thrombus load and its characteristics beyond the occlusion (microvascular obstruction (MVO), distal stenosis), which leads to complicate the primary angioplasty (PTCA) and to the no reflow phenomenon (NFP), which has an overall incidence reported from 20 to 40%. Objectives To evaluate the efficacy of the distal coronary angiography with microcatheter, that leads to an individualized therapeutic strategy, with the purpose of prevent the NFP in the accute coronary occlusion in STEMI treated with PTCA. Material and methods 70 patients were included with STEMI. We performed coronary angiography with microcatheter distal to the obstruction, and the therapeutic strategy was chosen in accordance with findings: stenosis, thrombus amount or MVO. After the PTCA were performed, we evaluated the NFP incidence. Results Report of 70 patients, the majority men (80%), class Killip Kimbal I (95 %), with disease of the right coronary artery in 57%, and anterior descending coronary artery in 37%. Distal thrombus was present in 47% of the studied patients. An obstruction length of more than 30 mm was observed in 21% of the cases, also we observed dissection of the arteries in a 21%, MVO was presented in 41%, and distal stenosis in 25%. Used therapeutic strategies: It was applied medicated stent in 81% of the patients, long balloon in 93%, and thrombolytic therapy in 30%. We observed a NFP incidence of 18.6 %. Conclusions The diagnostic and therapeutic approach for STEMI that this study recommends, diminishes the NFP in comparison with reported. An obstruction > 30 mm is an independent factor for NFP, therefore in these cases we recommend use the described diagnostic approach and long balloon.

Clinical Implication of the Presence of Notch Wave in ECG for Patients With Left Circumflex Artery-related Acute Myocardial Infarction / 中国循环杂志

Objectives: To evaluate the clinical implication of notch (N) Wave in ECG for patients with left circumflex artery-related acute myocardial infarction. Methods: A total of 416 patients with left circumflex artery-related acute myocardial infarction hospitalized in our hospital from January 2013 to December 2016 were included in this study. According to the electrocardiogram, 156 people were divided into ST segment elevation myocardial infarction group, 108 patients in N wave non-ST segment elevation myocardial infarction group, and 152 patients in non-N wave NSTEMI group. Troponin I and creatine kinase isoenzyme, hospitalization to operation time, vascular lesion site and degree, the intraoperative and postoperative complications were compared among the 3 groups. Results: Troponin I and creatine kinase isoenzyme levels were significantly lower in non-N wave NSTEMI group than in STEMI group and N wave NSTEMI group (P<0.05). The occurrence rate of no-reflow phenomenon was significantly higher in N wave NSTEMI group than in STEMI group and non N wave NSTEMI group (P<0.05). There was no significant difference in incidence of cardiac shock, ventricular fibrillation, ventricular aneurysm and death rate among the 3 groups(P>0.05). Incidence rate of lesion located in the proximal and middle section of left circumflex artery as well as the mean vascular stenosis degree were significantly lower, while incidence rate of lesion located in the distal section of left circumflex artery and obtuse marginal branches was significantly higher in non N wave NSTEMI group than in STEMI group and N wave NSTEMI group(P<0.05). Conclusions: Presence of Notch wave in ECG is associated with higher incidence of lesion located in the proximal and middle section of left circumflex artery, larger infarct size and higher incidence of no-reflow in patients with left circumflex artery-related acute myocardial infarction.

Application of thrombus aspiration technique in emergency percutaneous coronary intervention for patients with ST segment elevation myocardial infarction / 中国基层医药

Objective To evaluate the effect of thrombus aspiration technique in emergency percutaneous coronary intervention for patients with ST segment elevation myocardial infarction ( STEMI ) .Methods According to the digital table ,48 patients with acute anterior myocardial infarction were randomly into 22 cases of control group ( routine stent implantation ) and 26 cases of observation group ( thrombus aspiration and then stent implantation ) .The changes of TIMI grading , left ventricular ejection fraction , NT -ProBNP were compared between the two groups . Results There were no significant differences in baseline data between the two groups (all P>0.05).The proportion of TIMI grade III of immediate blood flow in the observation group after operation was higher than that in the control group(26 cases vs.16 cases,χ2 =4.810,P<0.05).The LVEF values of the observation group and the control group at 1 week after operation were better than those after 24 h,but there was no statistically significant difference between the two groups (t=1.803,1.796,all P>0.05).The level of NT-ProBNP at 1 week after operation in the observation group was significantly lower than that in the control group [(271.2 ±35.5)pg/mL vs.(806.5 ±65.8)pg/mL,t=3.154,P<0.05].Conclusion The thrombus aspiration technique can obviously reduce the occurrence of the "no reflow"in STEMI patients with high thrombus load receive PPCI ,improve the heart function .

Beclin-1 expression is upregulated by spermine in rat myocardial ische-mia-reperfusion injury / 中国病理生理杂志

AIM:To observe the effects of spermine(SP)on myocardial ischemia-reperfusion(IR)injury in rats.METHODS:SD rats(weighing 220~250 g)were equally randomized to 3 groups: sham control group, in which the rats were only treated with thoracotomy;IR group,in which the rats were treated with ischemia for 30 min and reperfu-sion for 60 min;and IR+SP group,in which 0.5 mmol/L SP(2 mL/kg)was intravenously injected just 15 min before reperfusion.The morphological changes of myocardial tissues were assessed by HE staining.The levels of cardiac troponin I(cTnI)and creatine kinase isoenzyme MB(CK-MB)in plasma were determined.Myocardial infarct size and no-reflow range of the myocardium were measured by Evans blue and thioflavin S staining.Inflammatory responses in the myocardial tissues were detected by myeloperoxidase(MPO)assay.The autophagy function was detected by measuring the protein ex-pression of beclin-1 by Western blot.RESULTS: The myocardial injury and inflammatory infiltration in IR +SP group were reduced under light microscope.Treatment with SP decreased the plasma levels of cTnI and CK-MB,and reduced the IR-induced infarct size and no-reflow range size of the left ventricle(P<0.05).Tissue MPO assay showed that myocardial inflammatory responses were attenuated in IR +SP group compared with IR group.Beclin-1 was upregulated in IR +SP group compared with IR group(P<0.05).CONCLUSION: Exogenous SP attenuates myocardial ischemia-reperfusion injury by upregulating the expression of beclin-1.

Relationship among CRP ,MAP levels and no-reflow during emergency PCI in patients with acute myocardial infarction / 心血管康复医学杂志

Objective :To explore relationship among levels of C reactive protein (CRP) ,mean platelet volume (MPV) and occurrence of no-reflow (NR) during primary percutaneous coronary intervention (PCI) in patients with acute ST elevation myocardial infarction (STEMI).Methods :Clinical and imaging data of 156 STEMI patients ,who received primary PCI from Jan 2015 to Dec 2016 ,were retrospectively analyzed .According to presence of NR during PCI ,patients were divided into NR group (n＝54) and no NR control group (n＝102).Multi-factor Logistic regression analysis was used to analyze influencing factors of NR occurrence .Results :Compared with no NR control group ,there were significant rise in percent-age of diabetes mellitus (23.5% vs.42.6%) ,levels of CRP [(31.7 ± 5.3)mg/Lvs.(64.5 ± 9.7)mg/L]and MPV [(9.31 ± 1.05)fl vs.(11.29 ± 0.98)fl] ,number of stents [(1.9 ± 0.4) vs.(2.1 ± 0.6)] and symptom-onset-to-balloon [SOTB , (254 ± 96)min vs.(315 ± 108)min] in NR group , P＜0.05 or ＜0.01. Multi-factor Logistic regression analysis indicated that diabetes mellitus ,SOTB ,levels of CRP and MPV were independent risk factors for NR occurrence (OR＝2.335～3.670 ,P＜0.05 or ＜0.01).Conclusion :Rise of CRP and MPV levels are independent risk factors for no-reflow during primary PCI in STEMI patients ,which possess certain predictive value for no-reflow occurrence and worth extending .

Influence of preoperative nicorandil application on coronary no-reflow in patients with acute anterior myocardial infarction / 心血管康复医学杂志

Objective:To explore influence of preoperative nicorandil application on coronary no-reflow during emer-gency percutaneous coronary intervention(PCI)in patients with acute anterior myocardial infarction(AAMI). Methods:A total of 116 AAMI patients were randomly and equally divided into routine treatment group and nic-orandil group(received nicorandil based on routine treatment).TIMI grade,incidence rate of no-reflow,ECG ST-segment elevation resolution(STR)and incidence rate of major adverse cardiovascular events(MACE)after PCI were compared between two groups.Results:Compared with routine treatment group after PCI,there were signifi-cant rise in percentage of infarct related artery(IRA)TIMI grade 3(77.6% vs.91.4%)and STR on 2h after PCI[(0.15 ± 0.05)mm vs.(0.18 ± 0.05)mm],and significant reductions in incidence rates of no-reflow(13.8% vs. 3.4%)and MACE(17.2% vs.5.2%)in nicorandil group after PCI,P<0.05 or <0.01. Conclusion:Preoperative nicorandil application can reduce incidence rate of no-reflow after PCI,improve myocardial perfusion and reduce in-cidence rate of major adverse cardiovascular events.

Research progress of no reflow phenomenon in patients with acute myocardial infarction during primary percutaneous coronary intervention / 中国医师杂志

Primary percutaneous coronary intervention is a main treatment for acute myocardial infarction.Although there is vast majority of patients with coronary artery to restore blood flow after percutaneous coronary interventional therapy opened the infarction related artery,no reflow phenomenon is frequently observed and seriously affect the prognosis of patients.The occurrence of no reflow in percutaneous coronary intervention (PCI) is associated with a variety of factors and the pathogenic mechanisms that cause this phenomenon are complex and interrelated.So a better understanding of these mechanisms could judge the possibility of no-reflow and promote the development of individualized prevention and treatment strategies are of great clinical significance for the prevention of no-reflow.