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)

Slow Flow Phenomenon Impairs the Prognosis of Coronary Artery Ectasia as Well as Coronary Atherosclerosis

Abstract Introduction: Coronary artery ectasia (CAE) is one of the uncommon cardiovascular disorders and its prognosis is still debated. Objective: We aimed to review long-term follow-up data in patients with CAE and to evaluate the prognosis of CAE patients with coronary slow flow phenomenon (CSFP). Methods: This study had a prospective design and 143 patients with CAE were included. The angiographic and demographic characteristics were reviewed in detail. The patients were categorized, based on concomitant coronary artery stenosis detected by angiography, as CCAE group (n=87, ≥30% luminal stenosis) and ICAE group (n=56, <30% luminal stenosis) and also categorized by the coronary flow as CSFP group (n=51) and normal flow coronary ectasia - NCEA group (n=92). All patients were re-evaluated at 6-month intervals. Follow-up data, cardiovascular (CV) mortality, hospitalization and major adverse cardiac events (MACE) were collected. The level of statistical significance was set at 5%. Results: Patients were followed up for an average of 56.9±7.4 months. During the follow-up, statistically significant differences were found in hospitalization, CV mortality and MACE between the CCAE and ICAE groups (P=0.038, P=0.003, P=0.001, respectively). The CSFP and NCEA groups were also compared. There was a statistical difference with respect to hospitalization between the CFSP and NCEA groups (P=0.001), but no difference was observed in terms of MACE and CV mortality (P=0.793 and P=0.279). Conclusion: CSFP accompanying CAE may be a predictor of hospitalization. Significant atherosclerotic plaques coexisting with CAE may be predictive for MACE.

O Escore Gensini e a Carga Trombótica Adicionam Valor Preditivo ao Escore SYNTAX na Detecção de No-Reflow após Infarto do Miocárdio / Gensini Score and Thrombus Burden Add Predictive Value to the SYNTAX Score in Detecting No-Reflow after Myocardial Infarction

Resumo Fundamento O fenômeno de no-reflow após a intervenção coronária percutânea está associado a um pior prognóstico em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). O escore SYNTAX é um bom preditor de no-reflow. Objetivo Nosso objetivo foi avaliar se a carga aterosclerótica (escore Gensini) e a carga trombótica na artéria coronária culpada melhorariam a capacidade do escore SYNTAX para detectar o no-reflow. Métodos Neste estudo coorte prospectivo, foram estudados pacientes com IAMCSST consecutivos que se apresentaram dentro de 12 horas a partir do início dos sintomas. O no-reflow foi definido como fluxo TIMI < 3 ou fluxo TIMI =3 mas grau de blush miocárdico (myocardial blush grade) < 2. A carga trombótica foi quantificada de acordo com o grau TIMI de trombo (0 a 5). Resultados Foram incluídos 481 pacientes no estudo, com idade média de 61±11 anos. O fenômeno de no-reflow ocorreu em 32,8% dos pacientes. O escore SYNTAX (OR=1,05, IC95% 1,01-1,08, p<0,01), a carga trombótica (OR=1,17, IC95% 1,06-1,31, p<0,01), e o escore Gensini (OR=1,37, IC95% 1,13-1,65, p<0,01) foram preditores independentes do no-reflow. Os escores combinados apresentaram uma maior área sob a curva quando comparados ao escore SYNTAX isolado (0,78 [0,73-0,82] vs 0,73 [0,68-0,78], p=0,03). A análise da melhora da reclassificação líquida (NRI) categórica (0,11 [0,01-0,22], p=0,02) e contínua (NRI>0) (0,54 [0,035-0,73], p<0.001) mostrou melhora na capacidade preditiva do no-reflow no modelo combinado, com melhora da discriminação integrada (IDI) de 0,07 (0,04-0,09, p<0,001). Conclusões Nossos achados sugerem que, em pacientes com IAMCSST submetidos à intervenção coronária percutânea, a carga aterosclerótica e a carga trombótica na artéria culpada adicionam valor preditivo ao escore SYNTAX na detecção do fenômeno no-reflow. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Abstract Background No-reflow after percutaneous coronary intervention is associated with poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). SYNTAX score is a good predictor of no-reflow. Objective We aimed to evaluate whether atherosclerotic burden (Gensini score) and thrombus burden in the culprit coronary artery would improve the ability of the SYNTAX score to detect no-reflow. Methods In this prospective cohort study, consecutive patients with STEMI who presented within 12 h of onset of symptoms were selected for this study. No-reflow was defined as TIMI flow < 3 o r TIMI flow = 3 but myocardial blush grade <2. Thrombus burden was quantified according to the TIMI thrombus grade scale (0 to 5). Results A total of 481 patients were included (mean age 61±11 years). No-reflow occurred in 32.8%. SYNTAX score (OR=1.05, 95%CI 1.01-1.08, p<0.01), thrombus burden (OR=1.17, 95%CI 1.06-1.31, p<0.01), and Gensini score (OR=1.37, 95%CI 1.13-1.65, p<0.01) were independent predictors of no-reflow. Combined scores had a larger area under the curve than the SYNTAX score alone (0.78 [0.73-0.82] vs 0.73 [0.68-0.78], p=0.03). Analyses of both categorical (0.11 [0.01-0.22], p=0.02), and continuous net reclassification improvement (NRI>0) (0.54 [0.035-0.73], p<0.001) showed improvement in the predictive ability of no-reflow in the combined model, with integrated discrimination improvement (IDI) of 0.07 (0.04-0.09, p<0.001). Conclusions Our findings suggest that, in patients with STEMI undergoing percutaneous coronary intervention, atherosclerotic burden and thrombus burden in the culprit artery add predictive value to the SYNTAX score in detecting the no-reflow phenomenon. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Desfechos em Pacientes com Fenômeno de No-Reflow Coronário e a Relação entre a Molécula-1 de Lesão Renal e o Fenômeno de No-Reflow Coronário / Outcomes in Coronary No-Reflow Phenomenon Patients and the Relationship between Kidney Injury Molecule-1 and Coronary No-Reflow Phenomenon

Resumo Fundamento O fenômeno de no-reflow coronário (CNP, do inglês Coronary no-reflow phenomenon) está associado a um risco aumentado de eventos cardiovasculares adversos maiores (ECAM). Objetivo Este estudo teve como objetivo avaliar a relação entre os níveis séricos da Molécula-1 de lesão renal (KIM-1) e o CNP em pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Métodos Este estudo incluiu um total de 160 pacientes (113 homens e 47 mulheres; média de idade: 61,65 ± 12,14 anos) com diagnóstico de IAMCSST. Os pacientes foram divididos em dois grupos, o grupo reflow (GR) (n = 140) e o grupo no-reflow (GNR) (n = 20). Os pacientes foram acompanhados durante um ano. Um valor de p<0,05 foi considerado significativo. Resultados O CNP foi observado em 12,50% dos pacientes. O nível de KIM-1 sérico foi significativamente maior no GNR do que no GR (20,26 ± 7,32 vs. 13,45 ± 6,40, p<0,001). O índice de massa corporal (IMC) foi significativamente maior no GNR do que no GR (29,41 (28,48-31,23) vs. 27,56 (25,44-31,03), p=0,047). A frequência cardíaca (FC) foi significativamente menor no GNR do que no GR (61,6 ± 8,04 vs. 80,37 ± 14,61, p<0,001). O escore do European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) foi significativamente maior no GNR do que no GR (3,06 ± 2,22 vs. 2,36 ± 2,85, p=0,016). A incidência de AVC foi significativamente maior no GNR do que no GR (15% vs. 2,90%, p=0,013). O nível basal de KIM-1 (OR = 1,19, IC 95%: 1,07-1,34, p=0,002) e HR (OR = 0,784, IC 95%: 0,69-0,88, p<0,001) foram os preditores independentes de CNP. Conclusão Em conclusão, os níveis séricos basais de KIM-1 e a FC mais baixa estão independentemente associados com CNP em pacientes com IAMCSST, e o acidente vascular cerebral foi significativamente maior no GNR em um ano de seguimento. (Arq Bras Cardiol. 2021; 116(2):238-247)

Abstract Background Coronary no-reflow phenomenon (CNP) is associated with an increased risk of major cardiovascular adverse events (MACE). Objective This study aimed to evaluate the relationship between serum Kidney Injury Molecule-1 (KIM-1) levels and CNP in patients with acute ST-segment elevation myocardial infarction (STEMI). Methods This study included a total of 160 patients (113 males and 47 females; mean age: 61.65±12.14 years) who were diagnosed with STEMI. The patients were divided into two groups, the reflow group (RG) (n=140) and the no-reflow group (NRG) (n=20). Patients were followed during one year. A p-value of <0.05 was considered significant. Results CNP was observed in 12.50% of the patients. Serum KIM-1 was significantly higher in the NRG than in the RG (20.26±7,32 vs. 13.45±6.40, p<0.001). Body mass index (BMI) was significantly higher in the NRG than in the RG (29.41 (28.48-31.23) vs. 27.56 (25.44-31.03), p=0.047). Heart rate (HR) was significantly lower in the NRG than in the RG (61.6±8.04 vs. 80.37±14.61, p<0.001). The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) was significantly higher in the NRG than in the RG (3.06±2.22 vs. 2.36±2.85, p=0.016). The incidence of stroke was significantly higher in the NRG than in the RG (15% vs. 2.90%, p=0.013). The baseline KIM-1 level (OR=1.19, 95% CI:1.07 to 1.34, p=0.002) and HR (OR=0.784, 95% CI:0.69 to 0.88, p<0.001) were the independent predictors of CNP. Conclusion In conclusion, baseline serum KIM-1 concentrations and lower HR are independently associated with CNP in STEMI patients and the incidence of stroke was significantly higher in the NRG in the one-year follow-up. (Arq Bras Cardiol. 2021; 116(2):238-247)

Determinação do Tecido Cicatricial do Miocárdio no Fenômeno de Fluxo Coronário Lento e a Relação entre a Quantidade de Tecido Cicatricial e o Nt-ProBNP / Determination of Myocardial Scar Tissue in Coronary Slow Flow Phenomenon and The Relationship Between Amount of Scar Tissue and Nt-ProBNP

Resumo Fundamento A fisiopatologia e o prognóstico não estão claramente determinados nos pacientes com fenômeno do fluxo coronário lento (FCL). Esses pacientes apresentam várias condições clínicas, que variam desde quadro assintomático até internação hospitalar com morte cardíaca súbita. Objetivos Nosso objetivo foi avaliar os achados da ressonância magnética cardíaca (RMC) com o realce tardio pelo gadolínio (RTG), como um indicador de fibrose miocárdica. Também buscamos determinar a relação entre a presença de fibrose miocárdica e os níveis de NT-proBNP em pacientes com FCL na artéria coronária descendente anterior esquerda (DAE). Métodos Ao todo, 35 pacientes, entre 31 e 75 anos de idade, foram incluídos. Os pacientes estudados (n=19) apresentaram artérias coronárias epicárdicas normais na angiografia, mas tinham FCL na DAE. O grupo controle de pacientes (n=16) apresentou artérias coronárias epicárdicas normais e níveis de escore TIMI normais na angiografia. Em ambos os grupos, os pacientes foram examinados com RMC para a detecção de presença de fibrose miocárdica. Além disso, níveis plasmáticos de NT-proBNP foram medidos. Valores de p < 0,05 foram considerados significativos. Resultados A taxa de fibrose miocárdica foi significativamente maior na RMC para os pacientes com FCL (p=0.018). Uma quantidade variável de tecido cicatricial foi detectada no ápice ventricular esquerdo em 7 pacientes e nas regiões inferior e inferolateral em 3 pacientes. Não foram observadas diferenças nos níveis de NT-proBNP nos pacientes com FCL. Entretanto, os níveis de NT-proBNP foram maiores nos pacientes com FCL, que apresentaram fibrose miocárdica na RMC (p=0.022). Conclusões Em suma, o RTG na RMC mostrou que a cicatriz miocárdica isquêmica pode estar presente nos pacientes com FCL. Esses resultados indicam que o FCL pode nem sempre ser inofensivo. (Arq Bras Cardiol. 2020; 114(3):540-551)

Abstract Background Pathophysiology and prognosis are not clearly determined in patients with the coronary slow flow phenomenon (CSFP). These patients present with various clinical conditions ranging from being asymptomatic to being admitted with sudden cardiac death. Objectives We aimed at assessing the findings of late gadolinium enhancement (LGE) in cardiac magnetic resonance imaging (CMR) as an indicator of myocardial fibrosis. We also aimed at determining the relationship between the presence of myocardial fibrosis and NT-proBNP levels in patients with CSFP in the left anterior descending coronary artery (LAD). Methods A total of 35 patients were enrolled within an age range of 31-75. The study patients (n=19) had normal epicardial coronary arteries at angiography, but they presented with CSFP in the LAD. The control group patients (n=16) had normal epicardial coronary arteries and TIMI scores at normal levels in angiography. In both groups, the patients were examined with CMR for the presence of myocardial fibrosis. In addition, plasma NT-proBNP levels were measured. A p-value < 0.05 was considered significant. Results The rate of myocardial fibrosis was significantly higher in CMR in the patients with CSFP (p=0.018). A variable amount of myocardial scar tissue was detected at the left ventricular apex in 7 patients and at the inferior and inferolateral regions in 3 patients. There was no difference in the level of NT-proBNP in patients with CSFP. However, the NT-proBNP levels were higher in patients with CSFP, who had scar tissue in CMR (p=0.022). Conclusions In conclusion, LGE in CMR showed that ischemic myocardial scarring may exist in patients with CSFP. These results indicate that CSFP may not always be innocent. (Arq Bras Cardiol. 2020; 114(3):540-551)

Effect of Shexiang Tongxin Dropping Pills () on the Immediate Blood Flow of Patients with Coronary Slow Flow / 中国结合医学杂志

OBJECTIVE@#To observe the immediate effect and safety of Shexiang Tongxin dropping pills (, STDP) on patients with coronary slow flow (CSF), and furthermore, to explore new evidence for the use of Chinese medicine in treating ischemic chest pain.@*METHODS@#Coronary angiography (CAG) with corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) was applied (collected at 30 frames/s). The treatment group included 22 CSF patients, while the control group included 22 individuals with normal coronary flow. CSF patients were given 4 STDP through sublingual administration, and CAG was performed 5 min after the medication. The immediate blood flow frame count, blood pressure, and heart rate of patients before and after the use of STDP were compared. The liver and kidney functions of patients were examined before and after treatments.@*RESULTS@#There was a significant difference in CTFC between groups (P0.05).@*CONCLUSIONS@#The immediate effect of STDP in treating CSF patients was apparent. This medication could significantly improve coronary flow without affecting blood pressure or heart rate. Our findings support the potential of Chinese medicine to treat ischemic chest pain.

Protective effect of dexmedetomidine against myocardial ischemia-reperfusion injury in rabbits

Abstract Purpose: To investigate the influence of dexmedetomidine on myocardial ischemia-reperfusion injury (IRI) in rabbits. Methods: Twenty-four New Zealand white rabbits were randomly divided into two equal-sized groups: IRI group (group IR) and dexmedetomidine group (group D). Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), left ventricular systolic pressure (LVSP), left ventricular end-diastolic pressure (LVEDP), left ventricular diastolic pressure (LVDP), +dp/dtmax, -dp/dtmax, and t-dp/dtmax were recorded and calculated at the following time points: before (T0) and after (T1) dexmedetomidine infusion, after 30-min ischemia (T2), and after 120-min reperfusion (T3). The levels of plasma endothelin 1 (ET-1), thromboxane A2 (TXA2), and platelet activating factor (PAF); area of myocardial infarction (MI); and no-reflow area were evaluated. Results: SBP, DBP, LVSP, LVEDP, LVDP, and +dp/dtmax at T3 were higher in group D than in group IR (P<0.05). The average no-reflow area in group IR was significantly smaller than that in group D (14±3% vs. 38±5%, P=0.0116). The ET-1, TXA2, and PAF levels at T2 and T3 were higher than those at T0 in both groups (P<0.05). Conclusion: Dexmedetomidine could reduce the magnitude of ischemic myocardial no-reflow area and protect the myocardium with ischemia-reperfusion injury.

Experimental study of histological changes in vascular loops according to the duration of the postoperative period: Application in reconstructive microsurgery

OBJECTIVES: To analyze the histological changes observed in venous grafts subjected to arterial blood flow as a function of the duration of the postoperative period to optimize their use in free flap reconstructions. METHOD: Twenty-five rats (7 females and 18 males) underwent surgery. Surgeries were performed on one animal per week. Five weeks after the first surgery, the same five animals were subjected to an additional surgery to assess the presence or absence of blood flow through the vascular loop, and samples were collected for histological analysis. This cycle was performed five times. RESULTS: Of the rats euthanized four to five weeks after the first surgery, no blood flow was observed through the graft in 80% of the cases. In the group euthanized three weeks after the first surgery, no blood flow was observed in 20% of the cases. In the groups euthanized one to two weeks after the first surgery, blood flow through the vascular loop was observed in all animals. Moreover, intimal proliferation tended to increase with the duration of the postoperative period. Two weeks after surgery, intimal proliferation increased slightly, whereas strong intimal proliferation was observed in all rats evaluated five weeks after surgery. CONCLUSION: Intimal proliferation was the most significant change noted in venous grafts as a function of the duration of the postoperative period and was directly correlated with graft occlusion. In cases in which vascular loops are required during free flap reconstruction, both procedures should preferably be performed during the same surgery.

Fenómeno de no reflow, una complicación frecuente en la revascularización del infarto. Caso clínico / No-Reflow Phenomenon, a Common Complication in Revascularization following Infarction. A Clinical Case

El fenómeno de no reflow consiste en la inadecuada perfusión de una región miocárdica luego de un período de isquemia, a pesar del restablecimiento del flujo epicárdico en la arteria que irriga dicha área. La ocurrencia de este fenómeno se asocia a peor pronóstico aunque su manejo es controvertido al no existir, hasta el momento, una terapia sólidamente establecida. El advenimiento de las nuevas técnicas de imágenes, como la tomografía cardíaca, permitió caracterizar de manera más precisa la repercusión miocárdica del fenómeno de no reflow. Presentamos el caso de un paciente con infarto inferior derivado a nuestro centro para angioplastia primaria, el cual se complicó con fenómeno de no reflow; posteriormente revisamos esta entidad clínica.

The no-reflow phenomenon is the inadequate perfusion of a myocardial area after an ischemic period, even though the epicardial flow is restored in the artery irrigating that area. The occurrence of this phenomenon is associated to a worse prognosis; although its management is controversial since there is no well-established therapy so far. The advent of new imaging techniques, such as cardiac tomography, has made it possible to describe myocardial repercussion of the no-reflow phenomenon more accurately. We are presenting the case of a patient with lower infarction referred to our center for a primary angioplasty, complicated with no-reflow phenomenon. Subsequently, we reviewed this clinical entity.

hsCRP and ET-1 expressions in patients with no-reflow phenomenon after Percutaneous Coronary Intervention

Objective: To explore hsCRP and ET-1 expressions in patients with no-reflow phenomenon after percutaneous coronary intervention [PCI]

Methods: A total of 136 patients with single coronary artery disease receiving PCI were divided into a reflow group and a no-reflow group to compare the level use of ET-1 alone with combined level of ET-1 and hs-CRP in PCI regarding sensitivity, specificity, positive and negative predictive values and accuracy for postoperative no-reflow. The study was conducted between 2014-2016 at our hospital

Results: Postoperative levels of ET-1 and hs-CRP in no-reflow group were significantly higher than those of reflow group [P<0.05]. ET-1 level of reflow group peaked three hours after PCI and then declined. Serum level of hs-CRP decreased most obviously within three hours after PCI in reflow group and three hours - three days after PCI in no-reflow group. Left ventricular end-diastolic diameters of both groups after PCI were apparently lower than those before PCI, without significant inter-group difference [P>0.05]. Left ventricular end-systolic diameters and left ventricular ejection fractions of both groups evidently increased after PCI, without significant inter-group differences either [P>0.05]. Corrected TIMI frame count [CTFC] and wall motion score index of reflow group after PCI were significantly lower than those of no-reflow group [P<0.05]. ET-1 level was positively correlated with CTFC [P<0.05]. Multivariate linear regression showed hs-CRP was negatively correlated with the serum level [P<0.05] [r=-0.34]

Conclusion: hsCRP and ET-1 levels significantly increased in patients with no-reflow phenomenon

In-Lab Upfront Use of Tirofiban May Reduce the Occurrence of No-Reflow During Primary Percutaneous Coronary Intervention. A Pilot Randomized Study / Uso de Tirofibana em Laboratório pode Reduzir Ocorrência de não Reperfusão Durante Intervenção Coronariana Percutânea Primária. Um Estudo Piloto Randomizado

Abstract Background: Despite successful opening of culprit coronary artery, myocardial reperfusion does not always follows primary percutaneous coronary intervention (PPCI). Glycoprotein IIb/IIIa inhibitors are used in the treatment of no-reflow (NR), but their role to prevent it is unproven. Objective: To evaluate the effect of in-lab administration of tirofiban on the incidence of NR in ST-elevation myocardial infarction (STEMI) treated with PPCI. Methods: STEMI patients treated with PPCI were randomized (24 tirofiban and 34 placebo) in this double-blinded study to assess the impact of intravenous tirofiban on the incidence of NR after PPCI according to angiographic and electrocardiographic methods. End-points of the study were: TIMI-epicardial flow grade; myocardial blush grade (MBG); resolution of ST-elevation < 70% (RST < 70%) at 90min and 24h after PPCI. Results: Baseline anthropometric, clinical and angiographic characteristics were balanced between the groups. The occurrence of TIMI flow < 3 was not significantly different between the tirofiban (25%) and placebo (35.3%) groups. MBG ≤ 2 did not occur in the tirofiban group, and was seen in 11.7% of patients in the placebo group (p=0.13). RST < 70% occurred in 41.6% x 55.8% (p=0.42) at 90min and in 29% x 55.9% (p=0.06) at 24h in tirofiban and placebo groups, respectively. Severe NR (RST ≤ 30%) was detected in 0% x 26.5% (p=0.01) at 90 min, and in 4.2% x 23.5% (p=0.06) at 24h in tirofiban and placebo groups, respectively. Conclusion: This pilot study showed a trend toward reduction of NR associated with in-lab upfront use of tirofiban in STEMI patients treated with PPCI and paves the way for a full-scale study testing this hypothesis.

Resumo Fundamento: Mesmo com abertura da artéria coronária culpada bem sucedida, a reperfusão miocárdica nem sempre sucede a intervenção coronariana percutânea primária (ICPP). Inibidores da glicoproteína IIb/IIIa são usados no tratamento do fenômeno de não reperfusão (NR), mas seu papel para preveni-lo não está comprovado. Objetivo: Avaliar o efeito da administração, em laboratório, de tirofibana sobre a incidência de NR em infarto agudo do miocárdio com supra do segmento ST (IAMCSST) tratado com ICPP. Métodos: Pacientes com IAMCSST tratados com ICPP foram randomizados (24 tirofibana e 34 placebo) neste estudo duplo-cego para avaliar o impacto de tirofibana intravenosa sobre a incidência de NR após ICPP de acordo com métodos angiográficos e eletrocardiográfico. Os desfechos do estudo foram: fluxo epicárdico TIMI (grau), grau de fluxo miocárdico (MBG), resolução da elevação do segmento ST < 70% (RST < 70%) aos 90 minutos e 24 horas após ICPP. Resultados: Características antropométricas, clínicas e angiográficas basais eram equilibradas entre os grupos. A ocorrência de fluxo TIMI < 3 não foi significativamente diferente entre os grupos tirofibana (25%) e placebo (35,3%). MBG ≤ 2 não ocorreu no grupo tirofibana, e foi detectado em 11,7% dos pacientes do grupo placebo (p=0,13). RST < 70% ocorreu em 41,6% x 55,8% (p=0.42) aos 90 minutos, e em 29% x 55,9% (p=0,06) em 24 horas nos grupos tirofibana e placebo, respectivamente. NR grave (RST ≤ 30%) ocorreu em 0% x 26,5% (p=0,01) aos 90 minutos, e em 4,2% x 23,5% (p=0,06) em 24 horas nos grupos tirofibana e placebo, respectivamente. Conclusão: Este estudo piloto mostrou uma tendência de redução de NR associada ao uso, em laboratório, de tirofibana em pacientes com IAMCSST tratados com ICPP, e abre caminho para um estudo em escala real que teste essa hipótese.

No-Reflow Phoenomenon by Intracoronary Thrombus in Acute Myocardial Infarction / 전남의대학술지

Recently, percutaneous coronary intervention has been the treatment of choice in most acute myocardial infarction cases. Although the results of percutaneous coronary interventions have ben good, the no-reflow phenomenon and distal embolization of intracoronary thrombus are still major problems even after successful interventions. In this article, we will briefly review the deleterious effects of no-reflow and distal embolization of intracoronary thrombus during percutaneous coronary interventions. The current trials focused on the prevention and treatment of the no-reflow phenomenon and intracoronary thrombus.

Long-Term Clinical Outcomes of Transient and Persistent No Reflow Phenomena following Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: There is limited information on the transient or persistent no reflow phenomenon in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). SUBJECTS AND METHODS: The study analyzed 4329 patients with AMI from a Korean multicenter registry who underwent PCI using coronary stents (2668 ST-elevation and 1661 non-ST-elevation myocardial infarction [MI] patients): 4071 patients without any no reflow, 213 with transient no reflow (no reflow with final thrombolysis in myocardial infarction [TIMI] flow grade 3), and 45 with persistent no reflow (no reflow with final TIMI flow grade≤2). The primary endpoint was all-cause mortality during 3-year follow-up. We also analyzed the incidence of cardiac mortality, non-fatal MI, re-hospitalization due to heart failure, target vessel revascularization, and stent thrombosis. RESULTS: The persistent no reflow group was associated with higher all-cause mortality (hazard ratio [HR] 1.98, 95% confidence interval [CI] 1.08-3.65, p=0.028) and cardiac mortality (HR 3.28, 95% CI 1.54-6.95, p=0.002) compared with the normal reflow group. Transient no reflow increased all-cause mortality only when compared with normal reflow group (HR 1.58, 95% CI 1.11-2.24, p=0.010). When comparing transient and persistent no reflow, persistent no reflow was associated with increased all-cause mortality (46.7 vs. 24.4%, log rank p=0.033). CONCLUSION: The persistent no reflow phenomenon was associated with a poor in-hospital outcome and increased long-term mortality mainly driven by increased cardiac mortality compared to the transient no reflow phenomenon or normal reflow.

Lethal coronary air embolism caused by the removal of a double-lumen hemodialysis catheter: a case report / 대한마취과학회지

Coronary air embolism is a rare event. We report a case in which an acute myocardial infarction occurred in the region supplied by the right coronary artery after the removal of a double-lumen hemodialysis catheter. Emergent coronary angiography revealed air bubbles obstructing the mid-segment of the right coronary artery with slow flow phenomenon distally. The patient expired due to myocardial infarction.

No-Reflow Phoenomenon by Intracoronary Thrombus in Acute Myocardial Infarction / 전남의대학술지

Recently, percutaneous coronary intervention has been the treatment of choice in most acute myocardial infarction cases. Although the results of percutaneous coronary interventions have ben good, the no-reflow phenomenon and distal embolization of intracoronary thrombus are still major problems even after successful interventions. In this article, we will briefly review the deleterious effects of no-reflow and distal embolization of intracoronary thrombus during percutaneous coronary interventions. The current trials focused on the prevention and treatment of the no-reflow phenomenon and intracoronary thrombus.

Increased neutrophil-to-lymphocyte ratio predicts persistent coronary no-flow after wire insertion in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVES: Acute ST-segment elevation myocardial infarction patients presenting persistent no-flow after wire insertion have a lower survival rate despite successful mechanical intervention. The neutrophil-to-lymphocyte ratio has been associated with increased mortality and worse clinical outcomes in ST-segment elevation myocardial infarction. We hypothesized that an elevated neutrophil-to-lymphocyte ratio would also be associated with a persistent Thrombolysis In Myocardial Infarction flow grade of 0 after wire insertion in patients undergoing primary percutaneous coronary intervention. METHODS: A total of 644 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention within 12 hours of symptom onset were included in our study. Blood samples were drawn immediately upon hospital admission. The patients were divided into 3 groups according to their Thrombolysis In Myocardial Infarction flow grade: Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion, Thrombolysis In Myocardial Infarction flow grade 1-3 after wire insertion and Thrombolysis In Myocardial Infarction flow grade 1-3 at baseline. RESULTS: The neutrophil-to-lymphocyte ratio was significantly higher in the group with Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion compared with the group with Thrombolysis In Myocardial Infarction flow grade 1-3 after wire insertion and the group with Thrombolysis In Myocardial Infarction flow grade 1-3 at baseline. The group with Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion also had a significantly higher in-hospital mortality rate. Persistent coronary no-flow after wire insertion was independently associated with the neutrophil-to-lymphocyte ratio. CONCLUSIONS: An increased neutrophil-to-lymphocyte ratio on admission is significantly associated with persistent coronary no-flow after wire insertion in patients with ST-segment ...

Roles of Intravascular Ultrasound in Patients with Acute Myocardial Infarction

Rupture of a vulnerable plaque and subsequent thrombus formation are important mechanisms leading to the development of an acute myocardial infarction (AMI). Typical intravascular ultrasound (IVUS) features of AMI include plaque rupture, thrombus, positive remodeling, attenuated plaque, spotty calcification, and thin-cap fibroatheroma. No-reflow phenomenon was attributable to the embolization of thrombus and plaque debris that results from mechanical fragmentation of the vulnerable plaque by percutaneous coronary intervention (PCI). Several grayscale IVUS features including plaque rupture, thrombus, positive remodeling, greater plaque burden, decreased post-PCI plaque volume, and tissue prolapse, and virtual histology-IVUS features such as large necrotic corecontaining lesion and thin-cap fibroatheroma were the independent predictors of no-reflow phenomenon in AMI patients. Non-culprit lesions associated with recurrent events were more likely than those not associated with recurrent events to be characterized by a plaque burden of > or =70%, a minimal luminal area of < or =4.0 mm2, or to be classified as thin-cap fibroatheromas.