Advances in Coronary No-Reflow Phenomenon-a Contemporary Review

Case Report: Smoking as the risk factor of persistent STEMI after primary percutaneous coronary intervention: how it could be happen?

Background

Acute coronary syndrome (ACS) remains one of the leading causes of death worldwide. Smoking may also increase the risk of developing ACS. The most advantageous therapy is percutaneous coronary intervention. However, this therapy may fail because of the no-reflow phenomenon. This case report describes a young male patient admitted to the emergency department due to ST-segment elevation of myocardial infarction (STEMI), with smoking as the only risk factor.

Case description

A 37-year-old male presented to our hospital with a typical chest pain. He was a heavy smoker. Electrocardiography (ECG) revealed extensive anterior STEMI. Coronary angiography revealed total occlusion of the proximal left anterior descending artery (LAD) with a high-burden thrombus. The no-reflow phenomenon occurs during Percutaneous Coronary intervention (PCI). After two days of hospitalization, the patient developed cardiogenic shock and acute decompensated heart failure. The patient was administered ticagrelor, acetylsalicylic acid, enoxaparin for three days, high-dose statins, and optimized heart failure treatment. The patient was discharged on the 7th day after admission.

Discussion

Cigarette smoke chemicals may induce atherosclerosis and thickened blood in the arteries. Lipid oxidation leads to plaque formation. If plaque ruptures, it will cause thrombus occlusion. A high-burden thrombus can induce a no-reflow phenomenon, leading to heart failure and cardiogenic shock.

Conclusion

Smoking may induce STEMI and tends to result in a high-burden thrombus. The no-reflow phenomenon is an evidence of miscarriage during PCI, which may increase because of smoking.

Efficacy and Safety of Alprostadil in Microcirculatory Disturbances During Emergency PCI: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The clinical advantage of alprostadil [prostaglandin E1 (PGE1)] in the treatment of microcirculatory disturbances (defined as no-reflow or slow-flow) in acute percutaneous coronary intervention (PCI) is still disputed. The purpose of our study was to review the efficacy of PGE1 supplements in patients with acute myocardial infarction (AMI) who had urgent PCI.

DESIGN

This study was a meta-analysis of randomized controlled trials.

DATA SOURCES

PubMed, Embase, the Cochrane Library, Ovid, ProQuest, Scopus, the Chinese BioMedical Literature Database, China National Knowledge Internet, the China Science and Technology Journal Database, and the Wanfang Data Knowledge Service Platform were used as sources.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included randomized controlled trials including PGE1 for the treatment of intraoperative microcirculatory disorders and major cardiovascular adverse events in emergency PCI in people with AMI. Independent data extraction was conducted, and study quality was assessed. The meta-analysis was carried out by using random effects models to calculate the risk ratio (RR) of microcirculatory disorders between groups receiving PGE1 and those receiving placebo, nitroglycerin, or tirofiban.

MAIN OUTCOME MEASURES

The primary endpoint of the study was the incidence of microcirculatory disturbances. Secondary outcomes included corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC), the percentage of patients with TIMI myocardial perfusion grade 3 (TMPG3), and the percentage of patients with myocardial blush grade 3 (MBG3) as efficacy indicators. Additionally, major adverse cardiovascular events (MACE) at 30 days and 180 days were assessed as safety indicators.

RESULTS

There were 18 trials involving a total of 1458 participants. PGE1 significantly reduced the occurrence of microcirculation disorders compared with conventional medications and placebo [risk ratio 0.48, 95% confidence interval (CI) 0.36-0.63, I2 = 46%; cTFC (RR -4.74, 95% -6.85 to -2.63, I2 93%); percentage of patients with TMPG3 (RR 1.34, 95% CI 1.07-1.68, I2 70%) or MBG3 (RR 1.33, 95% CI 1.19-1.49, I2 0%); major adverse cardiovascular events (MACEs) in 30 days (RR 0.48, 95% CI 0.27-0.86, I2 0%); and MACEs in 180 days (RR 0.41, 95% CI 0.28-0.60, I2 0%)].

CONCLUSIONS

We found that PGE1 decreased the occurrence of micro-circulation disturbance in AMI and enhanced the outcome of PCI. Additional studies should be conducted to confirm these findings.

Practical Approach to Diagnosis, Prevention, and Management of Coronary No-Reflow

Coronary no-reflow (NR) defined as inadequate myocardial perfusion despite restoration of coronary artery patency is a bane for an interventional cardiologist. It can complicate percutaneous coronary interventions especially in the setting of STEMI and dampens the potential benefits of PPCI. Broadly classified as Reperfusion NR and Interventional NR, mechanism is multifactorial. The basic underlying culprit is microvascular obstruction either secondary to distal embolization, intravascular plugging, or ischemic reperfusion injury. Coronary angiogram is an easy, readily available, and essential modality to diagnose no-reflow, but the gold standard is gadolinium-enhanced cardiovascular magnetic resonance imaging. Preventive strategies for NR should be integral part of prePCI planning especially in clinical scenario where NR is expected such as STEMI with delayed presentation and high thrombus burden, atherectomy, and SVG PCI. The cornerstone of treatment for NR is local vasodilators and antiplatelet therapy to ameliorate vasospasm and thromboembolism respectively, and different combinations of the two should be used in no specific order to achieve reversal of NR. NR phenomenon is associated with poor short-term and long-term prognosis and every attempt should be made to avoid or reverse it. Therapeutic hypothermia, hyperoxemic reperfusion therapy, targeted anti-inflammatory approach, and cellular approach appear proising but further research is mandatory.

Machine learning to predict no reflow and in-hospital mortality in patients with ST-segment elevation myocardial infarction that underwent primary percutaneous coronary intervention

BACKGROUND

The machine learning algorithm (MLA) was implemented to establish an optimal model to predict the no reflow (NR) process and in-hospital death that occurred in ST-elevation myocardial infarction (STEMI) patients who underwent primary percutaneous coronary intervention (pPCI).

METHODS

The data were obtained retrospectively from 854 STEMI patients who underwent pPCI. MLA was applied to predict the potential NR phenomenon and confirm the in-hospital mortality. A random sampling method was used to split the data into the training (66.7%) and testing (33.3%) sets. The final results were an average of 10 repeated procedures. The area under the curve (AUC) and the associated 95% confidence intervals (CIs) of the receiver operator characteristic were measured.

RESULTS

A random forest algorithm (RAN) had optimal discrimination for the NR phenomenon with an AUC of 0.7891 (95% CI: 0.7093-0.8688) compared with 0.6437 (95% CI: 0.5506-0.7368) for the decision tree (CTREE), 0.7488 (95% CI: 0.6613-0.8363) for the support vector machine (SVM), and 0.681 (95% CI: 0.5767-0.7854) for the neural network algorithm (NNET). The optimal RAN AUC for in-hospital mortality was 0.9273 (95% CI: 0.8819-0.9728), for SVM, 0.8935 (95% CI: 0.826-0.9611); NNET, 0.7756 (95% CI: 0.6559-0.8952); and CTREE, 0.7885 (95% CI: 0.6738-0.9033).

CONCLUSIONS

The MLA had a relatively higher performance when evaluating the NR risk and in-hospital mortality in patients with STEMI who underwent pPCI and could be utilized in clinical decision making.

MELD-XI score predict no-reflow phenomenon and short-term mortality in patient with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

INTRODUCTION

No-reflow phenomenon (NRP) is one of the complications that mostly occur during percutaneous coronary intervention (PCI). In this study, we comprehensively examined the relationship between the model for end-stage liver disease-XI (MELD-XI) score and NRP. Moreover, we discussed whether the MELD-XI score could be considered as an accurate risk assessment score of patients with ST-segment elevation myocardial infarction (STEMI) who are candidates for PCI.

METHODS

This retrospective study involved 693 patients with acute STEMI and who underwent an emergency PCI. They were divided into a normal reflow group or a no-reflow group on the basis of the flow rate of post-interventional thrombolysis in myocardial infarction. Univariate, multivariate logistic regression, and Cox regression analyses were performed to identify the independent predictors of NRP in both groups. Receiver operator characteristic (ROC) curves and Kaplan-Meier curves were plotted to estimate the predictive values of the MELD-XI score.

RESULTS

MELD-XI score was found to be an independent indicator of NRP (odds ratio: 1.247, 95% CI: 1.144-1.360, P < 0.001). Multivariate Cox regression analysis also revealed that the MELD-XI score is an independent prognostic factor for 30-day all-cause mortality (hazard ratio: 1.155, 95% CI: 1.077-1.239, P < 0.001). Moreover, according to the ROC curves, the cutoff value of the MELD-XI score to predict NRP was 9.47 (area under ROC curve: 0.739, P < 0.001). The Kaplan-Meier curves for 30-day all-cause mortality revealed lower survival rate in the group with a MELD-XI score of > 9.78 (P < 0.001).

CONCLUSION

The MELD-XI score can be used to predict NRP and the 30-day prognosis in patients with STEMI who are candidates for primary PCI. It could be adopted as an inexpensive and a readily available tool for risk stratification.

Luteolin alleviates ischemia/reperfusion injury-induced no-reflow by regulating Wnt/β-catenin signaling in rats

The no-reflow phenomenon induced by ischemia-reperfusion (I/R) injury seriously limits the therapeutic value of coronary recanalization and leads to a poor prognosis. Previous studies have shown that luteolin (LUT) is a vasoprotective factor. However, whether LUT can be used to prevent the no-reflow phenomenon remains unknown. Positron emission tomography perfusion imaging, performed to detect the effects of LUT on the no-reflow phenomenon in vivo, revealed that LUT treatment was able to reduce the no-reflow area in rat I/R models. In vitro, LUT was shown to reduce the hypoxia-reoxygenation injury-induced endothelial permeability and apoptosis. The levels of malondialdehyde, reactive oxygen species and NADPH were also measured and the results indicated that LUT could inhibit the oxidative stress. Western blot analysis revealed that LUT protected endothelial cells from I/R injury by regulating the Wnt/β-catenin pathway. Overall, we concluded that the use of LUT to minimize I/R induced microvascular damage is a feasible strategy to prevent the no-reflow phenomenon.

Endothelial Dysfunction and Coronary Vasoreactivity - A Review of the History, Physiology, Diagnostic Techniques, and Clinical Relevance

The fervency for advancement and evolution in percutaneous coronary intervention has revolutionised the treatment of coronary artery disease. Historically, the focus of the interventional cardiologist was directed at the restoration of luminal patency of the major epicardial coronary arteries, yet whilst this approach is evolving with much greater utilisation of physiological assessment, it often neglects consideration of the role of the coronary microcirculation, which has been shown to clearly influence prognosis. In this review, we explore the narrative of the coronary circulation as more than just a simple conduit for blood but an organ with functional significance. We review organisation and physiology of the coronary circulation, as well as the current methods and techniques used to examine it. We discuss the studies exploring coronary artery endothelial function, appreciating that coronary artery disease occurs on a spectrum of disorder and that percutaneous coronary intervention has a latent effect on the coronary circulation with long-term consequences. It is concluded that greater recognition of the coronary artery endothelium and mechanisms of the coronary circulation should further guide revascularisation strategies.

New CHA2DS2-VASc-HSF score predicts the no-reflow phenomenon after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction

BACKGROUND

The no-reflow phenomenon (NRP) is a serious complication of primary percutaneous coronary intervention (PPCI) and is an independent predictor of poor prognosis. We aimed to find a simple but effective risk stratification method for the prediction of NRP.

METHODS

This retrospective single-center study included 454 consecutive patients diagnosed with acute ST-segment elevation myocardial infarction (STEMI) and treated by PPCI, who were admitted to our emergency department between January 2017 and March 2019. The patients were divided according to the post-PPCI thrombolysis in the myocardial infarction flow rate: the NRP group and the control group. The CHADS₂, CHA₂DS₂-VASc, and CHA₂DS₂-VASc-HSF scores were calculated for all the patients in this study, and multivariable regression and receiver operating characteristic curve analyses were conducted to determine the independent predictors of NRP and the predictive value of the three scores.

RESULTS

A total of 454 patients were analyzed in this study: 80 in the no-reflow group and 374 in the control group. The incidence of NRP was 17.6%. Creatine kinase-myocardial band, Killip class, stent length, and multivessel disease also independently predicted NRP. The CHA₂DS₂-VASc-HSF score had a higher predictive value than the other two scores, and a CHA₂DS₂-VASc-HSF score of ≥4 predicted NRP with a sensitivity of 72.5% and specificity of 66.5% (area under the curve: 0.755, 95% confidence interval [0.702-0.808]).

CONCLUSION

Although the CHADS₂, CHA₂DS₂-VASc, and CHA₂DS₂-VASc-HSF scores can all be used as simple tools to predict NRP, our findings show that the CHA₂DS₂-VASc-HSF score had the highest predictive value. Thus, the CHA₂DS₂-VASc-HSF score may be an optimal tool for predicting high-risk patients.

Platelet/lymphocyte ratio for prediction of no-reflow phenomenon in ST-elevation myocardial infarction managed with primary percutaneous coronary intervention

Background

Coronary no-reflow phenomenon in ST-segment elevation myocardial infarction (STEMI) is associated with a poor clinical outcome. Although its pathophysiology is not fully understood, a deregulated systemic inflammatory response plays an important role. We aimed to explore the relationship between platelet\lymphocyte ratio (PLR) and no-reflow in patients with acute STEMI who were treated with a primary percutaneous coronary intervention (PPCI).

Methods

A total of 200 patients with STEMI undergoing PPCI were included in the study. Transthoracic echocardiographic examination was performed to assess left ventricular (LV) ejection fraction (EF) and wall motion score index. Blood samples were assayed for platelet and lymphocyte count before PPCI. No-reflow was defined as coronary blood flow thrombolysis in myocardial infarction grade ≤II.

Results

No-reflow was observed in 58 (29%) of STEMI patients following PPCI. PLR was significantly higher in hypertensive patients compared to normotensive patients (144.7±91.6 vs. 109.1±47.1, respectively, P<0.001) and in the no-reflow group compared to the normal reflow group (214±93 vs. 101.6±51.3, respectively, P<0.0001). Logistic regression analysis revealed that PLR (β: 0.485, 95% CI: -0.006-0.001, P<0.002) and LV EF (β: 0.272, 95% CI: 0.009-0.034, P<0.001) were independent predictors of no-reflow after PPCI.

Conclusion

Pre-procedural increase in PLR is predictive of the no-reflow phenomenon following PPCI in STEMI patients.

Relevance for Patients

No reflow phenomenon is an unfavorable complication following PPCI in patients with acute STEMI. High pre-procedural PLR is an independent predictor of reperfusion failure and helps to identify patients who require prophylactic treatment.

D-dimer level predicts in-hospital adverse outcomes after primary PCI for ST-segment elevation myocardial infarction

BACKGROUND

Use of D-dimer for prognostication of patients with ST-segment elevation myocardial infarction (STEMI) remains controversial and undefined among those with angiographically evident thrombus or no-reflow phenomenon.

METHODS

We retrospectively analyzed consecutive STEMI patients who received primary percutaneous coronary intervention (PCI) at Zhongshan Hospital Fudan University from January 2008 to December 2018. Outcomes were in-hospital major adverse cardiovascular events (MACE: cardiac death, non-fatal acute myocardial infarction, re-vascularization and stroke), peak troponin T and NT-proBNP levels, left ventricular ejection fraction (LVEF) and hospitalization duration.

RESULTS

Among 1165 patients, those with increased (≥0.8 mg/L, n = 224, 19.2%) vs. normal (n = 941, 80.8%) D-dimer level were older; more often women and non-smokers. Increased D-dimer group had similar frequency of AET (58.7% vs. 62.1%, P = .353), more frequently no-reflow phenomenon (13.1% vs. 18.8%, P = .028), higher peak values of troponin T (3.5 [0.9-7.0] vs. 4.5 [1.8-8.7], P = .001) and NT-proBNP (903.3 [532.3-2098.5] vs. 2070.0 [859.1-4378.0], p < .001). In increased D-dimer group, LVEF (53.3 ± 8.3 vs. 48.8 ± 9.8, P < .001) was lower, hospitalization was longer (8.0 ± 4.9 vs. 10.5 ± 6.9 days, P < .001) and risk of developing in-hospital MACE (1.5% vs. 12.1%, P < .001) was greater. D-dimer level was an independent risk factor for MACE (OR 8.408, 95%CI 4.065-17.392, P < .001), including the angiographically evident thrombus (OR 6.939, 95% CI 2.944-16.355, P < .001) and the no-reflow (OR 8.114, 95% CI 1.598-41.196, P = .012) subgroups.

CONCLUSIONS

Increased D-dimer level was an independent risk factor for in-hospital MACE in STEMI patients undergoing primary PCI, including those with angiographically evident thrombus and no-reflow phenomenon. D-dimer was not associated to no-reflow phenomenon in STEMI patients.

Circulating miR-660-5p is associated with no-reflow phenomenon in patients with ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVE

This study aims to investigate the association of circulating miR-660-5p with no-reflow phenomenon (NRP) in patients with ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).

METHODS

Consecutive patients diagnosed with anterior STEMI within 12 h of pain onset were included; in these patients, coronary angiography confirmed that the left anterior descending artery was infarcted. Angiographic NRP was defined as a final thrombolysis in myocardial infarction (TIMI) flow 2 or 3 with a myocardial blush grade (MBG) <2. High miR-660-5p was defined as a value in the third tertile. The relationship of circulating miR-660-5p with NRP was assessed using Spearman correlation analysis and multiple logistic regression analysis.

RESULTS

Fifty-two eligible patients were finally included in this study (mean age: 56±12.4 years, >65 years: 53.8%, male: 76.9%, and mean Body Mass Index: 26.3±3.5). The incidence of NRP was 38.5%. Circulating miR-660-5p was significantly related to the mean platelet volume (MPV). The patients were grouped into tertiles by miR-660-5p levels (Q1: <7.18, Q2: 7.18-11.31, Q3: >11.31). Those in the high microRNA-660-5p group had nearly a 6-fold higher risk of NRP than those in the low microRNA-660-5p group [odds ratio (OR) = 5.68, 95% confidence interval (CI) 1.40-23.07, p=0.015]. When analyzed by tertiles, relative odds of NRP were consistently increasing (OR1 for Q2 vs. Q1: 1.25, 95% CI: 0.27-5.73, p=0.770; OR2 for Q3 vs. Q1: 5.96, 95% CI: 1.33-26.66, p=0.02), despite multivariable adjustment. Receiver operating characteristic curve analysis demonstrated that the microRNA-660-5p level of 10.17 was the best cut-off level to predict the incidence of the NRP in patients undergoing PPCI with an area under the ROC curve (AUC) of 0.768 (95% CI: 0.636-0.890).

CONCLUSION

Circulating miR-660-5p was significantly associated with NRP, and it may be a useful biomarker to predict the incidence of NRP in patients with STEMI undergoing PPCI.

Shock Index on Admission Is Associated with Coronary Slow/No Reflow in Patients with Acute Myocardial Infarction Undergoing Emergent Percutaneous Coronary Intervention

Objective

Coronary slow/no reflow is not rare after successfully undergoing primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI), and shock index (SI) is an important factor for adverse cardiovascular prognosis. In this study, we are to explore whether SI is associated with coronary slow/no reflow in patients with AMI following primary PCI.

Methods

A total of 153 consecutive AMI patients undergoing primary PCI within 24 hours of symptom onset were included in this study. The participants were divided into normal flow group (n=124) and slow/no reflow group (n=29) according to cineangiograms recorded during the period of PCI. Cardiovascular risk factors, hematologic parameters, preoperative management of antithrombotic therapy, and baseline angiography were collected.

Results

SI, plasma glucose, white blood cells (WBC) and neutrophil count, neutrophil to lymphocyte ratio (PLR), high sensitivity C-reactive protein (hs-CRP), probrain natriuretic peptide (pro-BNP), and Killip classification on admission and thrombus burden on initial angiography were significantly different between patients with and without slow/no reflow. Multivariate analysis revealed that SI≥0.66, thrombus burden, and plasma glucose on admission were independent predictors for coronary slow/no reflow. Preoperative management of tirofiban therapy improves initial thrombolysis in myocardial infarction (TIMI). However, it has no effect on prognosis of slow/no reflow.

Conclusion

Our findings demonstrated that slow/no reflow in patients with AMI following primary PCI was more likely associated with SI≥0.66, thrombus burden, and plasma glucose on admission. SI as a predictor for coronary slow/no reflow should be further confirmed in the following more large-scale and prospective studies. The clinical registration number is ChiCTR1900024447.