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Huang W, Lindner JR. The Evolving Status of Cavitation Therapy in Acute Myocardial Infarction. J Am Soc Echocardiogr 2024:S0894-7317(24)00347-X. [PMID: 38986919 DOI: 10.1016/j.echo.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 07/04/2024] [Indexed: 07/12/2024]
Affiliation(s)
- Weiting Huang
- Cardiovascular Division and Robert M. Berne Cardiovascular Research Center, University of Virgina, Charlottesville, Virginia
| | - Jonathan R Lindner
- Cardiovascular Division and Robert M. Berne Cardiovascular Research Center, University of Virgina, Charlottesville, Virginia.
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2
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Laborante R, Bianchini E, Restivo A, Ciliberti G, Galli M, Vergallo R, Rodolico D, Zito A, Princi G, Leone AM, Aurigemma C, Romagnoli E, Montone RA, Burzotta F, Trani C, Crea F, D'Amario D. Adenosine as adjunctive therapy in acute coronary syndrome: a meta-analysis of randomized controlled trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:173-182. [PMID: 36496163 DOI: 10.1093/ehjcvp/pvac069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/18/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
AIMS Adenosine has been tested in several randomized controlled trials (RCTs) to minimize the incidence of coronary microvascular obstruction (CMVO). The aim of this study was to pool all the RCTs comparing intracoronary or intravenous adenosine versus placebo in patients with acute coronary syndrome (ACS) undergoing myocardial revascularization. METHODS AND RESULTS PubMed and Scopus electronic databases were scanned for eligible studies up to 5th June 2022. A total of 26 RCTs with 5843 patients were included. Efficacy endpoints were major adverse cardiac events (MACE), all-cause death, non-fatal myocardial infarction, and heart failure. Atrioventricular blocks and ventricular fibrillation/sustained ventricular tachycardia (VF/SVT) were the safety endpoints. Myocardial blush grade, thrombolysis in myocardial infarction (TIMI) flow grade, left ventricular ejection fraction (LVEF), infarct size, and ST-segment resolution were also assessed. Adenosine administration was not associated with any clinical benefit in terms of MACE, all-cause death, non-fatal myocardial infarction, and heart failure. However, adenosine was associated with an increased rate of advanced atrioventricular blocks and of VF/SVT in studies with total mean ischaemic time >3 h, compared to placebo. Remarkably, among patients undergoing percutaneous coronary intervention, adenosine was associated with reduced myocardial blush grade 0-1 and TIMI flow grade 0-2, compared to placebo. Furthermore, adenosine did not show favourable effects on LVEF and infarct size. CONCLUSION Adenosine infusion, as adjunctive therapy in ACS, was associated with an increased risk of advanced atrioventricular blocks and increased rates of adenosine-triggered ventricular arrhythmias in patients with long ischaemic time, without providing any clinical benefit compared to placebo.
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Affiliation(s)
- Renzo Laborante
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - Emiliano Bianchini
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - Attilio Restivo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - Giuseppe Ciliberti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - Mattia Galli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy.,Department of Cardiology, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Cotignola 48033, Italy
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Daniele Rodolico
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - Andrea Zito
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - Giuseppe Princi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy.,Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy.,Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy.,Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Domenico D'Amario
- Department of Translational Medicine, Università del Piemonte Orientale, Padiglione G, L.go Bellini, Novara, NO, 28100, Italy
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3
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Beijnink CWH, Woelders ECI, van Geuns RJM. No-Reflow After Primary PCI: Will Distal Intracoronary Medication Do the Trick? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:5-7. [PMID: 36682836 DOI: 10.1016/j.carrev.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Casper W H Beijnink
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eva C I Woelders
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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Kumar D, Ahmed I, Bardooli F, Saghir T, Sial JA, Khan KA, Farooq F, Chachar TS, Karim M, Kumar H, Bai R, Qamar N. Techniques to Treat Slow-Flow/No-Reflow During Primary Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:1-4. [PMID: 36266151 DOI: 10.1016/j.carrev.2022.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/29/2022] [Accepted: 09/22/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of this study was to compare TIMI flow after administering intracoronary (IC) medications through various routes for the treatment of slow flow/no-reflow during primary PCI. METHODS Two independent parallel cohorts of the patients who underwent primary PCI for STEMI and developed slow/no-reflow were recruited. Selection of cohort was based on the route of administration of IC medications as proximal or distal. Post administration TIMI follow was compared between the two cohorts. RESULTS A total of 100 patients were included in both, proximal and distal, cohort. Distribution of angiographic, clinical and demographic characteristics was not significant between the two cohorts except prevalence of hypertension, and diabetes mellitus. Frequency of hypertension, and diabetes mellitus were 45 % vs.70 %; p < 0.001 and 28 % vs. 44 %; p = 0.018 among patients in distal and proximal cohort respectively. Final TIMI III flow was achieved in significantly higher number of patients in distal cohort with the frequency of 88 % vs. 76 %; p = 0.027 as compared to proximal cohort. CONCLUSION Administration of IC medication via distal route is observed to be more effective for the treatment of slow flow/no-reflow during primary PCI. Distal route via export catheter or perforated balloon technique should be preferred wherever feasible.
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Affiliation(s)
- Dileep Kumar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan.
| | - Iftikhar Ahmed
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Fawaz Bardooli
- Mohammed Bin Khalifa Bin Sulman Al Khalifa Cardiac Centre (KMCC), Bahrain
| | - Tahir Saghir
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Jawaid Akbar Sial
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Kamran Ahmed Khan
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Fawad Farooq
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | | | - Musa Karim
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | | | | | - Nadeem Qamar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
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Kumar K, Singh N, Yadav HN, Maslov L, Jaggi AS. Endless Journey of Adenosine Signaling in Cardioprotective Mechanism of Conditioning Techniques: Clinical Evidence. Curr Cardiol Rev 2023; 19:56-71. [PMID: 37309766 PMCID: PMC10636797 DOI: 10.2174/1573403x19666230612112259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 05/11/2023] [Indexed: 06/14/2023] Open
Abstract
Myocardial ischemic injury is a primary cause of death among various cardiovascular disorders. The condition occurs due to an interrupted supply of blood and vital nutrients (necessary for normal cellular activities and viability) to the myocardium, eventually leading to damage. Restoration of blood supply to ischemic tissue is noted to cause even more lethal reperfusion injury. Various strategies, including some conditioning techniques, like preconditioning and postconditioning, have been developed to check the detrimental effects of reperfusion injury. Many endogenous substances have been proposed to act as initiators, mediators, and end effectors of these conditioning techniques. Substances, like adenosine, bradykinin, acetylcholine, angiotensin, norepinephrine, opioids, etc., have been reported to mediate cardioprotective activity. Among these agents, adenosine has been widely studied and suggested to have the most pronounced cardioprotective effects. The current review article highlights the role of adenosine signaling in the cardioprotective mechanism of conditioning techniques. The article also provides an insight into various clinical studies that substantiate the applicability of adenosine as a cardioprotective agent in myocardial reperfusion injury.
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Affiliation(s)
- Kuldeep Kumar
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab 147002, India
| | - Nirmal Singh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab 147002, India
| | - Harlokesh Narayan Yadav
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
| | - Leonid Maslov
- Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russia
| | - Amteshwar Singh Jaggi
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab 147002, India
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6
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Tehrani DM, Seto AH. Management of Coronary Complications. Interv Cardiol Clin 2022; 11:445-453. [PMID: 36243489 DOI: 10.1016/j.iccl.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Coronary complications are increasingly rare but remain fatal if not managed promptly and effectively. We review the incidence, management, and prevention of the most serious coronary complications including acute vessel closure from dissection, no-reflow, thrombosis, and air embolism as well as mechanical complications including perforation, stent dislodgment, and atherectomy burr entrapment.
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Affiliation(s)
- David M Tehrani
- University of California Los Angeles, 650 Charles East Young Drive South, A20237 CHS, Los Angeles, CA 90095, USA.
| | - Arnold H Seto
- Long Beach Veterans Administration Medical Center, 5901 East 7th Street 111C, Long Beach, CA 90822, USA
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Khan KA, Kumar R, Shah JA, Farooq F, Shaikh Q, Kumar D, Sial JA, Saghir T, Achakzai AS, Karim M. Comparison of angiographic results and clinical outcomes of no-reflow after stenting in left anterior descending (LAD) versus non-LAD culprit STEMI. SAGE Open Med 2022; 10:20503121221088106. [PMID: 35387152 PMCID: PMC8977700 DOI: 10.1177/20503121221088106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/23/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives: No-reflow is a complication that frequently occurs after stenting during primary percutaneous coronary intervention. In this study, we focused on angiographic results and clinical outcomes after no-reflow in the left anterior descending (LAD) artery versus non–left anterior descending artery ST-elevation myocardial infarction (STEMI). Methods: In this prospective study, a total of 201 patients who had developed no-reflow during primary percutaneous coronary intervention were enrolled. The patients were divided into left anterior descending artery culprit and non-left anterior descending artery culprit groups. The primary endpoints were final thrombolysis in myocardial infarction flow, corrected thrombolysis in myocardial infarction frame count and final myocardial blush grade. Secondary endpoints were major adverse cardiovascular events in-hospital and at 1 month. Results: Out of the 201 patients, 60.19% had culprit left anterior descending artery. Pulse rate, baseline systolic and diastolic blood pressure, single-vessel disease, left ventricular ejection fraction <30%, baseline thrombolysis in myocardial infarction I flow and final thrombolysis in myocardial infarction II flow (24.8% vs 11.3%, p = .017), and thrombolysis in myocardial infarction frame count (28.17 ± 11.86 vs 24.38 ± 9.05, p = .016) were significantly higher in the left anterior descending artery group. In contrast, baseline Killip Class I, three-vessel disease, baseline thrombolysis in myocardial infarction II flow, final thrombolysis in myocardial infarction III flow (74.4% vs 87.5%, p = .024) and left ventricular ejection fraction >40% were significantly greater in the non–left anterior descending artery group. However, for both in-hospital and at 30 days, overall major adverse cardiovascular event was similar in the two groups. The demographics, clinical and medication profiles and the routes used to treat no-reflow were all comparable in both groups. Conclusions: No-reflow in left anterior descending artery ST-elevation myocardial infarction is associated with lower final thrombolysis in myocardial infarction III flow, higher thrombolysis in myocardial infarction frame count and relatively lower Grade III myocardial blush than non-left anterior descending artery ST-elevation myocardial infarction with subsequent lower left ventricular ejection fraction and a higher frequency of in-hospital heart failure and hospitalisation due to heart failure.
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Affiliation(s)
- Kamran Ahmed Khan
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Rajesh Kumar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Jehangir Ali Shah
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Fawad Farooq
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Quratulain Shaikh
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Dileep Kumar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Jawaid Akbar Sial
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Tahir Saghir
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | | | - Musa Karim
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
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8
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Khan KA, Qamar N, Saghir T, Sial JA, Kumar D, Kumar R, Qayyum D, Yasin U, Jalbani J, Karim M. Comparison of Intracoronary Epinephrine and Adenosine for No-Reflow in Normotensive Patients With Acute Coronary Syndrome (COAR Trial). Circ Cardiovasc Interv 2022; 15:e011408. [PMID: 35000456 PMCID: PMC8843359 DOI: 10.1161/circinterventions.121.011408] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Intracoronary epinephrine has been effectively used in treating refractory no-reflow, but there is a dearth of data on its use as a first-line drug in normotensive patients in comparison to the widely used adenosine. Methods: In this open-labeled randomized clinical trial, 201 patients with no-reflow were randomized 1:1 into intracoronary epinephrine as the treatment group and intracoronary adenosine as the control group and followed for 1 month. The primary end points were improvement in coronary flow, as assessed by TIMI (Thrombolysis in Myocardial Infarction) flow, frame counts, and myocardial blush. Secondary end points were in-hospital and short-term mortality and major adverse cardiac events. Results: In all, 101 patients received intracoronary epinephrine and 100 patients received adenosine. Epinephrine was generally well tolerated with no immediate table death or ventricular fibrillation. No-reflow was more effectively improved with epinephrine with final TIMI III flow (90.1% versus 78%, P=0.019) and final corrected TIMI frame count (24±8.43 versus 26.63±9.22, P=0.036). However, no significant difference was observed in final grade III myocardial blush (55.4% versus 45%, P=0.139), mean reduction of corrected TIMI frame count (−25.71±11.79 versus −26.08±11.71, P=0.825), in-hospital and short-term mortality, and major adverse cardiac events. Conclusions: Epinephrine is relatively safe to use in no-reflow in normotensive patients. A significantly higher frequency of post-treatment TIMI III flow grade and lower final corrected TIMI frame count with relatively better achievement of myocardial blush grade III translate into it displaying relatively better efficacy than adenosine. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04699110.
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Affiliation(s)
- Kamran Ahmed Khan
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Nadeem Qamar
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Tahir Saghir
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Jawaid Akbar Sial
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Dileep Kumar
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Rajesh Kumar
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Danish Qayyum
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Umamah Yasin
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Javed Jalbani
- Department of Adult Cardiology (K.A.K., N.Q., T.S., J.A.S., D.K., R.K., D.Q., U.Y., J.J.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Musa Karim
- Department of Clinical Research (M.K.), National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
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Procopio MC, Lauro R, Nasso C, Carerj S, Squadrito F, Bitto A, Di Bella G, Micari A, Irrera N, Costa F. Role of Adenosine and Purinergic Receptors in Myocardial Infarction: Focus on Different Signal Transduction Pathways. Biomedicines 2021; 9:biomedicines9020204. [PMID: 33670488 PMCID: PMC7922652 DOI: 10.3390/biomedicines9020204] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/15/2021] [Indexed: 12/24/2022] Open
Abstract
Myocardial infarction (MI) is a dramatic event often caused by atherosclerotic plaque erosion or rupture and subsequent thrombotic occlusion of a coronary vessel. The low supply of oxygen and nutrients in the infarcted area may result in cardiomyocytes necrosis, replacement of intact myocardium with non-contractile fibrous tissue and left ventricular (LV) function impairment if blood flow is not quickly restored. In this review, we summarized the possible correlation between adenosine system, purinergic system and Wnt/β-catenin pathway and their role in the pathogenesis of cardiac damage following MI. In this context, several pathways are involved and, in particular, the adenosine receptors system shows different interactions between its members and purinergic receptors: their modulation might be effective not only for a normal functional recovery but also for the treatment of heart diseases, thus avoiding fibrosis, reducing infarcted area and limiting scaring. Similarly, it has been shown that Wnt/β catenin pathway is activated following myocardial injury and its unbalanced activation might promote cardiac fibrosis and, consequently, LV systolic function impairment. In this regard, the therapeutic benefits of Wnt inhibitors use were highlighted, thus demonstrating that Wnt/β-catenin pathway might be considered as a therapeutic target to prevent adverse LV remodeling and heart failure following MI.
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Affiliation(s)
- Maria Cristina Procopio
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
| | - Rita Lauro
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
| | - Chiara Nasso
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
| | - Francesco Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
| | - Alessandra Bitto
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic “G. Martino”, 98165 Messina, Italy;
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
- Correspondence: ; Tel.: +39-090-221-3093; Fax: +39-090-221-23-81
| | - Francesco Costa
- Department of Clinical and Experimental Medicine, University of Messina, 98165 Messina, Italy; (M.C.P.); (R.L.); (C.N.); (S.C.); (F.S.); (A.B.); (G.D.B.); (F.C.)
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Kumar V, Sharma AK, Kumar T, Nath RK. Large intracoronary thrombus and its management during primary PCI. Indian Heart J 2020; 72:508-516. [PMID: 33357638 PMCID: PMC7772595 DOI: 10.1016/j.ihj.2020.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/22/2020] [Accepted: 11/07/2020] [Indexed: 11/07/2022] Open
Abstract
Large intracoronary thrombus has been reported in significant number of patients with STEMI. Primary PCI is the current standard of care in patients of STEMI. Despite the availability of dual antiplatelets, GP IIb/IIIa inhibitor and effective anticoagulation regimens, large intracoronary thrombus remains one of the biggest challenge to interventional cardiologists during primary PCI. Large intracoronary thrombus may lead to distal embolization, no/slow reflow or embolization into a non-culprit vessel and is associated with adverse cardiovascular outcome. There is no ideal management strategy. We hereby discuss the current available methods/strategies to deal with large thrombus burden encountered during primary PCI, in the current manuscript.
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Affiliation(s)
- Vinod Kumar
- Department of Cardiology, Dr Ram Manohar Lohia Hospital & PGIMER, New Delhi, 110001, India.
| | - Ajay Kumar Sharma
- Department of Cardiology, Dr Ram Manohar Lohia Hospital & PGIMER, New Delhi, 110001, India.
| | - Tarun Kumar
- Department of Cardiology, Dr Ram Manohar Lohia Hospital & PGIMER, New Delhi, 110001, India.
| | - Ranjit Kumar Nath
- Department of Cardiology, Dr Ram Manohar Lohia Hospital & PGIMER, New Delhi, 110001, India.
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11
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Hyeon CW, Lee W, Kim SY, Park JY, Shin SH. Prevention of medical malpractice and disputes through analysis of lawsuits related to coronary angiography and intervention. Korean J Intern Med 2020; 35:605-618. [PMID: 31189300 PMCID: PMC7214373 DOI: 10.3904/kjim.2018.365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 01/07/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Possible fatal complications arising from coronary angiography (CAG), percutaneous coronary intervention (PCI), and coronary artery disease itself, are likely to cause medical disputes. Presenting the current status and reasons for judgments given in lawsuits related to CAG/PCI, this study aimed to identify ways to prevent unnecessary disputes and medical malpractice suits related to CAG/PCI through lawsuit analysis. METHODS A total of 13 cases (20 judgments) found in the Supreme Court of Korea's Written Judgment Management System from 1998 to 2017 were analyzed. RESULTS Coronary artery injury was the most common causative complication that led to lawsuits (n = 6, 46%). Six cases (46%) were ruled in favor of the plaintiff for violation of duty of care (n = 4) and duty of explanation (n = 2), respectively. Cases that violated duty of care included two errors in intra-procedure device manipulation, one in pre-procedure diagnosis, and one in management of post-procedure complication. Lack of explanation regarding the risk of complications was pointed out in both cases that violated duty of explanation. The average awarded amount for the damages was 114,436,064 Korean won. CONCLUSION Physicians need not fear unfair judgments so long as they follow standard of care because the Court consistently looked at the probability, the foreseeability, and the evidence. Therefore, maintaining standard of care is important. Besides, specific, detailed, and comprehensible explanations, including the risk of complications in addition to the necessity of procedures, are important to ensure the patient clearly understands the possible risk of adverse outcomes.
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Affiliation(s)
- Cheol Won Hyeon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Lee
- Division of Medical Law and Bioethics, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Seoul, Korea
- Asian Institute for Bioethics and Health Law, Yonsei University, Seoul, Korea
| | - So Yoon Kim
- Division of Medical Law and Bioethics, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Seoul, Korea
- Asian Institute for Bioethics and Health Law, Yonsei University, Seoul, Korea
| | | | - Su Hwan Shin
- Doctoral Program in Medical Law and Ethics, Yonsei University, Seoul, Korea
- Blue Urology Clinic, Seoul, Korea
- Correspondence to Su Hwan Shin, M.D. Blue Urology Clinic, 99 Sinchon-ro, Seodaemun-gu, Seoul 03779, Korea Tel: +82-2-365-5671 Fax: +82-2-365-5673 E-mail:
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12
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Giannini F, Candilio L, Mitomo S, Ruparelia N, Chieffo A, Baldetti L, Ponticelli F, Latib A, Colombo A. A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2019; 11:1797-1810. [PMID: 30236352 DOI: 10.1016/j.jcin.2018.05.052] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/07/2018] [Accepted: 05/29/2018] [Indexed: 12/13/2022]
Abstract
Percutaneous coronary intervention relieves symptoms in patients with chronic ischemic heart disease resistant to optimal medical therapy and alters the natural history of acute coronary syndromes. However, adverse procedural outcomes may occur during the intervention. Knowledge of possible complications and their timely management are essential for the practicing cardiologist and can be life-saving for the patient. In this review, the authors summarize potential complications of percutaneous coronary intervention focusing on their practical management.
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Affiliation(s)
- Francesco Giannini
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Luciano Candilio
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy; Cardiovascular Department, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Satoru Mitomo
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Neil Ruparelia
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alaide Chieffo
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Baldetti
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ponticelli
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Azeem Latib
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Colombo
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Bai S, Liu H, Wu H, Wang X, Li R, Li X, Li X, Zhang L, Chen T, Du R. Predictive value of soluble suppression of tumourigenicity 2 on myocardial reperfusion. Intern Med J 2019; 50:985-992. [PMID: 31566840 DOI: 10.1111/imj.14639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/25/2019] [Accepted: 08/28/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND High baseline level of soluble suppression of tumourigenicity 2 (sST2) was an independent predictor of cardiovascular death and heart failure in ST-segment elevation myocardial infarction (STEMI). AIMS To investigate the value of serum sST2 baseline levels in predicting myocardial reperfusion in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). METHODS Consecutive STEMI patients who underwent PPCI within 12 h after the onset of chest pain were enrolled, and were divided into Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion grading (TMPG) 0/1/2 group and TMPG 3 group based on post-procedural TMPG. Baseline clinical characteristics, lesions and procedural characteristics were compared. Univariate logistic regression and multivariate linear logistic analysis were performed to identify independent predictors of impaired myocardial reperfusion (TMPG 0/1/2). Receiver-operating characteristics curve (ROC) analysis of sST2 was performed to identify the optimum cut-off value for predicting the myocardial reperfusion. RESULTS A total of 121 patients was enrolled in this study. Univariate logistic regression analysis showed that Killip II-III, high levels of sST2 and brain natriuretic peptide were risk factors of TMPG 0/1/2. Multivariable logistic regression analysis revealed that sST2 was an independent predictor of impaired myocardial reperfusion (odds ratio 12.318, 95% confidence interval 4.567-33.220, P < 0.001). ROC curve analysis showed that the area under curve of sST2 was 0.849, and the best cut-off value was 2.003 ng/mL, with a sensitivity of 89.2% and a specificity of 67.9%. CONCLUSION The elevated levels of sST2 on admission were associated with impaired myocardial reperfusion in STEMI patients undergoing PPCI.
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Affiliation(s)
- Shiru Bai
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Huiliang Liu
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Haibo Wu
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Xuechao Wang
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Ruyi Li
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Xiangming Li
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Xinning Li
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Lina Zhang
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Tianlei Chen
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
| | - Rongpin Du
- Department of Cardiology, Hebei Provincial General Hospital, Shijiazhuang, China
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Abstract
The no-reflow phenomenon relates to the inability to reperfuse regions of the myocardium after ischemia, despite removal of the large epicardial coronary artery occlusion. The mechanism involves microvascular obstruction. In experimental studies, using markers for flow (thioflavin S, carbon black, microspheres), perfusion defects associated with no-reflow demonstrated ultrastructural evidence of localized endothelial swelling and blebs that appeared to obstruct flow. In humans no-reflow is more complicated due to the microemboli of atherosclerotic debris and thrombi generated by percutaneous coronary intervention. The no-reflow zone expands during the first few hours of reperfusion suggesting an element of reperfusion injury. In animal models, extensive no-reflow was associated with worse infarct expansion. The phenomenon of no-reflow following reperfusion therapy for myocardial infarction in humans has been demonstrated by magnetic resonance imaging, echo contrast agents, thallium, technecium-99m-labeled albumin microspheres, Thrombolysis In Myocardial Infarction (TIMI) scores, and myocardial blush grade. Patients exhibiting no-reflow following reperfusion therapy for myocardial infarction have greater left ventricular dilation and remodeling, more congestive heart failure, shock, and reduced survival. Certain vasodilators (adenosine, nitroprusside, nicorandil, and calcium blockers) are used acutely in the catheterization laboratory and appear to improve no-reflow, but systematic studies on therapy for no-reflow are needed. There is now clinical evidence that no-reflow is a strong predictor of long-term mortality that is independent of and beyond that provided by infarct size. Identifying and treating no-reflow may have important benefits including enhancing delivery of nutrients and cells required for healing and reducing infarct expansion and ventricular remodeling, which ultimately may reduce congestive heart failure and mortality.
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Affiliation(s)
- Robert A. Kloner
- Heart Institute, Good Samaritan Hospital, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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15
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Abstract
Cellular stress or apoptosis triggers the release of ATP, ADP and other nucleotides into the extracellular space. Extracellular nucleotides function as autocrine and paracrine signalling molecules by activating cell-surface P2 purinergic receptors that elicit pro-inflammatory immune responses. Over time, extracellular nucleotides are metabolized to adenosine, leading to reduced P2 signalling and increased signalling through anti-inflammatory adenosine (P1 purinergic) receptors. Here, we review how local purinergic signalling changes over time during tissue responses to injury or disease, and we discuss the potential of targeting purinergic signalling pathways for the immunotherapeutic treatment of ischaemia, organ transplantation, autoimmunity or cancer.
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Affiliation(s)
- Caglar Cekic
- Department of Molecular Biology and Genetics, Bilkent University, Ankara 06800, Turkey
| | - Joel Linden
- Division of Developmental Immunology, La Jolla Institute for Allergy and Immunology, La Jolla, California 92037, USA
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Intracoronary administration of different doses of anisodamine in primary percutaneous coronary intervention. Coron Artery Dis 2016; 27:302-10. [DOI: 10.1097/mca.0000000000000366] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gargiulo G, Moschovitis A, Windecker S, Valgimigli M. Developing drugs for use before, during and soon after percutaneous coronary intervention. Expert Opin Pharmacother 2016; 17:803-18. [DOI: 10.1517/14656566.2016.1145666] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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18
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Bulluck H, Sirker A, Loke YK, Garcia-Dorado D, Hausenloy DJ. Clinical benefit of adenosine as an adjunct to reperfusion in ST-elevation myocardial infarction patients: An updated meta-analysis of randomized controlled trials. Int J Cardiol 2016; 202:228-37. [PMID: 26402450 PMCID: PMC4669305 DOI: 10.1016/j.ijcard.2015.09.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/08/2015] [Accepted: 09/04/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adenosine administered as an adjunct to reperfusion can reduce coronary no-reflow and limit myocardial infarct (MI) size in ST-segment elevation myocardial infarction (STEMI) patients. Whether adjunctive adenosine therapy can improve clinical outcomes in reperfused STEMI patients is not clear and is investigated in this meta-analysis of 13 randomized controlled trials (RCTs). METHODS We performed an up-to-date search for all RCTs investigating adenosine as an adjunct to reperfusion in STEMI patients. We calculated pooled relative risks using a fixed-effect meta-analysis assessing the impact of adjunctive adenosine therapy on major clinical endpoint including all-cause mortality, non-fatal myocardial infarction, and heart failure. Surrogate markers of reperfusion were also analyzed. RESULTS 13 RCTs (4273 STEMI patients) were identified and divided into 2 subgroups: intracoronary adenosine versus control (8 RCTs) and intravenous adenosine versus control (5 RCTs). In patients administered intracoronary adenosine, the incidence of heart failure was significantly lower (risk ratio [RR] 0.44 [95% CI 0.25-0.78], P=0.005) and the incidence of coronary no-reflow was reduced (RR for TIMI flow<3 postreperfusion 0.68 [95% CI 0.47-0.99], P=0.04). There was no difference in heart failure incidence in the intravenous adenosine group but most RCTs in this subgroup were from the thrombolysis era. There was no difference in non-fatal MI or all-cause mortality in both subgroups. CONCLUSION We find evidence of improved clinical outcome in terms of less heart failure in STEMI patients administered intracoronary adenosine as an adjunct to reperfusion. This finding will need to be confirmed in a large adequately powered prospective RCT.
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Affiliation(s)
- Heerajnarain Bulluck
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, NIHR University College London Hospitals Biomedical Research Centre, University College London, Chenies Mews, London, WC1E 6HX, UK; The Heart Hospital, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - Alex Sirker
- The Heart Hospital, 16-18 Westmoreland Street, London W1G 8PH, UK
| | - Yoon K Loke
- University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - David Garcia-Dorado
- Cardiology Department, Valld'Hebron Hospital, Universitat Autónomade Barcelona, Barcelona, Spain
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, NIHR University College London Hospitals Biomedical Research Centre, University College London, Chenies Mews, London, WC1E 6HX, UK; The Heart Hospital, 16-18 Westmoreland Street, London W1G 8PH, UK; Cardiovascular and Metabolic Disorders Program, Duke-NUS Graduate Medical School, Singapore, Singapore; National Heart Research Institute Singapore, National Heart Centre Singapore.
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Bouleti C, Mewton N, Germain S. The no-reflow phenomenon: State of the art. Arch Cardiovasc Dis 2015; 108:661-74. [PMID: 26616729 DOI: 10.1016/j.acvd.2015.09.006] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/28/2015] [Accepted: 09/07/2015] [Indexed: 02/06/2023]
Abstract
Primary percutaneous coronary intervention (PCI) is the best available reperfusion strategy for acute ST-segment elevation myocardial infarction (STEMI), with nearly 95% of occluded coronary vessels being reopened in this setting. Despite re-establishing epicardial coronary vessel patency, primary PCI may fail to restore optimal myocardial reperfusion within the myocardial tissue, a failure at the microvascular level known as no-reflow (NR). NR has been reported to occur in up to 60% of STEMI patients with optimal coronary vessel reperfusion. When it does occur, it significantly attenuates the beneficial effect of reperfusion therapy, leading to poor outcomes. The pathophysiology of NR is complex and incompletely understood. Many phenomena are known to contribute to NR, including leukocyte infiltration, vasoconstriction, activation of inflammatory pathways and cellular oedema. Vascular damage and haemorrhage may also play important roles in the establishment of NR. In this review, we describe the pathophysiological mechanisms of NR and the tools available for diagnosing it. We also describe the microvasculature and the endothelial mechanisms involved in NR, which may provide relevant therapeutic targets for reducing NR and improving the prognosis for patients.
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Affiliation(s)
- Claire Bouleti
- Service de cardiologie, hôpital Bichat, AP-HP, Paris, France; DHU FIRE, université Paris Diderot, Paris, France; Collège de France, Center for Interdisciplinary Research in Biology (CIRB), Paris, France; CNRS/UMR 7241, Paris, France; Inserm U 1050, Paris, France
| | - Nathan Mewton
- Hôpital cardiovasculaire Louis-Pradel, centre d'investigation clinique unité, hospices civils de Lyon, Bron, France; Inserm U 1407, Lyon, France
| | - Stéphane Germain
- Collège de France, Center for Interdisciplinary Research in Biology (CIRB), Paris, France; CNRS/UMR 7241, Paris, France; Inserm U 1050, Paris, France.
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Polimeni A, De Rosa S, Sabatino J, Sorrentino S, Indolfi C. Impact of intracoronary adenosine administration during primary PCI: A meta-analysis. Int J Cardiol 2015; 203:1032-41. [PMID: 26630632 DOI: 10.1016/j.ijcard.2015.11.086] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 11/09/2015] [Accepted: 11/15/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Aim of the present study was to evaluate all randomized trials, comparing intracoronary adenosine versus placebo in STEMI patients undergoing primary PCI. METHODS AND RESULTS PubMed, the Cochrane Library and ISI Web of Knowledge electronic databases were scanned for eligible studies up to February 23rd 2015. The summary measure used was risk ratio (RR) with 95% confidence intervals. A total of 13 studies were eligible, including 1487 patients. Incidence of ST resolution was significantly higher in the IC adenosine group than in the placebo group (RR = 1.20 [1.05–1.38]; p = 0.008). At metaregression, a significant correlation was found between the magnitude of the adenosine-related effect on ST resolution and the mean ischemic time (p = 0.011) or the percentage of patients with the LAD as the infarct-related artery (p = 0.03). Furthermore, we found a larger increase in LVEF (p = 0.02) with a parallel reduction in the incidence of heart failure (HF) (RR = 0.50 [0.28–0.89]; p = 0.02) in the IC adenosine group. Finally, IC adenosine administration was associated with a significantly lower incidence of major adverse cardiac events (MACE) both at short- (RR = 0.62 [0.39–0.98] p = 0.04) and long-term (RR = 0.61 [0.39–0.95] p = 0.03). CONCLUSIONS This is the first meta-analysis demonstrating a clinical benefit for IC adenosine in hard endpoints, such as adverse cardiovascular events, in patients undergoing primary PCI.
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Affiliation(s)
- Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy; URT-CNR, Department of Medicine, Consiglio Nazionale delle Ricerche, Catanzaro, Italy.
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Gao Q, Yang B, Guo Y, Zheng F. Efficacy of Adenosine in Patients With Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A PRISMA-Compliant Meta-Analysis. Medicine (Baltimore) 2015; 94:e1279. [PMID: 26266362 PMCID: PMC4616690 DOI: 10.1097/md.0000000000001279] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/04/2015] [Accepted: 06/05/2015] [Indexed: 11/27/2022] Open
Abstract
Whether adenosine offers cardioprotective effects when used as an adjunctive therapy for patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) remains controversial.To evaluate, via meta-analysis, the efficacy of adenosine in patients with AMI undergoing PCI.Randomized controlled trials (RCTs) published in Medline, Embase, and the Cochrane Central Register of Controlled Trials.RCTs of patients with AMI undergoing primary PCI, comparing adenosine treatment and placebo groups and reporting mortality, thrombolysis in myocardial infarction (TIMI) flow grade, myocardial blush grade (MBG), re-infarction, left-ventricular ejection fraction (LVEF), ST-segment elevation resolution (STR), recurrent angina, or heart failure (HF).Risk of bias was assessed by the Cochrane guidelines and publication bias by Egger's test. For studies reported in multiple publications, the most complete publication was used. Arms using different dosing schedules were merged. Mean differences (MDs) or risk ratios (RRs) were determined.Data were extracted from 15 RCTs involving 1736 patients. Compared with placebo, adenosine therapy was associated with fewer occurrences of heart failure (RR: 0.65, 95% confidence interval [CI]: 0.43-0.97, P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.03) and no-reflow (TIMI flow grade <3, RR: 0.62, 95% CI: 0.45-0.85, P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.003; MBG[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0-1, RR: 0.81; 95% CI: 0.67-0.98, P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.03), more occurrences of STR (RR: 1.19, 95% CI: 1.07-1.31, P[REPLACEMENT CHARACTER]<[REPLACEMENT CHARACTER]0.00001), but no overall improvement of LVEF (MD: 2.29, 95% CI: -0.09 to 4.67, P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.06). Adenosine improved LVEF in the intravenous subgroup and the regular-dose intracoronary (IC) subgroup (0.24-2.25[REPLACEMENT CHARACTER]mg) compared with placebo (MD: 2.68, 95% CI: 0.66-4.70, P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.009). Adenosine was associated with a poorer LVEF in the high-dose (4-6[REPLACEMENT CHARACTER]mg) IC subgroup (MD: -2.40; 95% CI: -4.72 to -0.09, P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.04). There was no significant evidence that adenosine reduced rates of all-cause mortality, cardiovascular mortality or re-infarction after PCI.Adenosine dosage and administration routes, baseline profiles, and endpoints differed among included RCTs. Performance, publication, and reporting biases remain possible.Adenosine therapy appears to improve several outcomes in patients with AMI after PCI, but there is no evidence that adenosine can reduce mortality rates.
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Affiliation(s)
- Qijun Gao
- From the Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, P.R. China (QG, BY); Department of Cardiology, First People's Hospital of Tianmen, Tianmen, Hubei Province, P.R. China (QG); Department of Epidemiology, School of Public Health, Wuhan University, Wuhan, Hubei, P.R. China (YG); and Medical Faculty, University of Cologne, Cologne, Germany (FZ)
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Adenosine as an Adjunct Therapy in ST Elevation Myocardial Infarction Patients: Myth or Truth? Cardiovasc Drugs Ther 2015; 29:481-93. [DOI: 10.1007/s10557-015-6606-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Su Q, Nyi TS, Li L. Adenosine and verapamil for no-reflow during primary percutaneous coronary intervention in people with acute myocardial infarction. Cochrane Database Syst Rev 2015; 2015:CD009503. [PMID: 25985145 PMCID: PMC7388181 DOI: 10.1002/14651858.cd009503.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PPCI) is the preferred treatment for ST-segment elevation myocardial infarction. Although coronary flow is restored after PPCI, impaired myocardial perfusion (known as no-reflow) related to poor clinical outcomes is frequently observed. To overcome this phenomenon, drugs, such as atorvastatin, abciximab and others, have been tried as adjunctive treatment to PPCI. Among these drugs, verapamil and adenosine are among the most promising. No other systematic reviews have examined use of these two drugs in people with acute myocardial infarction (AMI) undergoing PPCI. This is an update of the version previously published (2013, Issue 6), for which the people of interest in the review were those treated with PPCI - not those given fibrinolytic therapy. OBJECTIVES To study the impact of adenosine and verapamil on no-reflow during PPCI in people with AMI. SEARCH METHODS We updated searches of the following databases in June 2014 without language restriction: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science and BIOSIS, China National Knowledge Infrastructure and clinical trials registers (ClinicalTrials.gov, Current Controlled Trials, Australian and New Zealand Clinical Trials Registry, the World Health Organization (WHO) International Clinical Trials Registry Platform). We also handsearched The American Journal of Cardiology. SELECTION CRITERIA We selected randomised controlled trials (RCTs) in which adenosine or verapamil was the primary intervention. Participants were individuals diagnosed with AMI who were undergoing PPCI. DATA COLLECTION AND ANALYSIS Two review authors collected studies and extracted data. When necessary, we contacted trial authors to obtain relevant information. We calculated risk ratios (RRs), P values and 95% confidence intervals (CIs) of dichotomous data. MAIN RESULTS We included in our review 11 RCTs (one new study with 59 participants) involving 1027 participants. Ten RCTs were associated with adenosine and one with verapamil. We considered the overall risk of bias of included studies to be moderate. We found no evidence that adenosine reduced short-term all-cause mortality (RR 0.61, 95% CI 0.25 to 1.48, P value = 0.27), long-term all-cause mortality (RR 0.78, 95% CI 0.22 to 2.74, P value = 0.70), short-term non-fatal myocardial infarction (RR 1.32, 95% 0.33 to 5.29, P value = 0.69) or myocardial blush grade (MBG) 0 to 1 after PPCI (RR 0.96, 95% CI 0.76 to 1.22, P value = 0.75). The incidence of thrombolysis in myocardial infarction (TIMI) flow grade < 3 after PPCI (RR 0.62, 95% CI 0.42 to 0.91, P value = 0.01) was decreased. Conversely, adverse events with adenosine, such as bradycardia (RR 6.32, 95% CI 2.98 to 13.41, P value < 0.00001), hypotension (RR 11.43, 95% CI 2.75 to 47.57, P value = 0.0008) and atrioventricular (AV) block (RR 6.78, 95% CI 2.15 to 21.38, P value = 0.001), were significantly increased.Meta-analysis of verapamil as treatment for no-reflow during PPCI was not performed because data were insufficient. AUTHORS' CONCLUSIONS It is difficult to draw conclusions because of the insufficient quality and quantity of current research studies. We considered the overall risk of bias of included studies to be moderate. Adenosine as treatment for no-reflow during PPCI could reduce angiographic no-reflow (TIMI flow grade < 3) but was found to increase adverse events. What's more, no evidence could be found to suggest that adenosine reduced all-cause mortality, non-fatal myocardial infarction or the incidence of myocardial blush grade 0 to 1. Additionally, the efficacy of verapamil for no-reflow during PPCI could not be analysed because data were insufficient. Further clinical research into adenosine and verapamil is needed because of the limited numbers of available trials and participants.
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Affiliation(s)
- Qiang Su
- The First Affiliated Hospital of Guangxi Medical UniversityDepartment of CardiologyNo. 6, Shuang Yong LoadNanningGuangxiChina530021
| | - Tun Swe Nyi
- The First Affiliated Hospital of Guangxi Medical UniversityDepartment of CardiologyNo. 6, Shuang Yong LoadNanningGuangxiChina530021
| | - Lang Li
- The First Affiliated Hospital of Guangxi Medical UniversityDepartment of CardiologyNo. 6, Shuang Yong LoadNanningGuangxiChina530021
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Novel insights into an “old” phenomenon: the no reflow. Int J Cardiol 2015; 187:273-80. [DOI: 10.1016/j.ijcard.2015.03.359] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 03/21/2015] [Accepted: 03/23/2015] [Indexed: 12/31/2022]
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Burnstock G, Pelleg A. Cardiac purinergic signalling in health and disease. Purinergic Signal 2015; 11:1-46. [PMID: 25527177 PMCID: PMC4336308 DOI: 10.1007/s11302-014-9436-1] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 11/25/2014] [Indexed: 01/09/2023] Open
Abstract
This review is a historical account about purinergic signalling in the heart, for readers to see how ideas and understanding have changed as new experimental results were published. Initially, the focus is on the nervous control of the heart by ATP as a cotransmitter in sympathetic, parasympathetic, and sensory nerves, as well as in intracardiac neurons. Control of the heart by centers in the brain and vagal cardiovascular reflexes involving purines are also discussed. The actions of adenine nucleotides and nucleosides on cardiomyocytes, atrioventricular and sinoatrial nodes, cardiac fibroblasts, and coronary blood vessels are described. Cardiac release and degradation of ATP are also described. Finally, the involvement of purinergic signalling and its therapeutic potential in cardiac pathophysiology is reviewed, including acute and chronic heart failure, ischemia, infarction, arrhythmias, cardiomyopathy, syncope, hypertrophy, coronary artery disease, angina, diabetic cardiomyopathy, as well as heart transplantation and coronary bypass grafts.
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Affiliation(s)
- Geoffrey Burnstock
- Autonomic Neuroscience Centre, University College Medical School, Rowland Hill Street, London, NW3 2PF, UK,
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Nazir SA, Khan JN, Mahmoud IZ, Greenwood JP, Blackman DJ, Kunadian V, Been M, Abrams KR, Wilcox R, Adgey AAJ, McCann GP, Gershlick AH. The REFLO-STEMI trial comparing intracoronary adenosine, sodium nitroprusside and standard therapy for the attenuation of infarct size and microvascular obstruction during primary percutaneous coronary intervention: study protocol for a randomised controlled trial. Trials 2014; 15:371. [PMID: 25252600 PMCID: PMC4189551 DOI: 10.1186/1745-6215-15-371] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 09/10/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Microvascular obstruction (MVO) secondary to ischaemic-reperfusion injury is an important but underappreciated determinant of short- and longer-term outcome following percutaneous coronary intervention (PCI) treatment of ST-elevation myocardial infarction (STEMI). Several small studies have demonstrated a reduction in the degree of MVO utilising a variety of vasoactive agents, with adenosine and sodium nitroprusside (SNP) being most evaluated. However, the evidence base remains weak as the trials have had variable endpoints, differing drug doses and delivery. As such, the results regarding benefit are conflicting. METHODS The REperfusion Facilitated by LOcal adjunctive therapy in STEMI (REFLO-STEMI) trial is a multicentre, prospective, randomised, controlled, open label, study with blinded endpoint analysis: Patients presenting within 6 h of onset of STEMI and undergoing planned primary PCI (P-PCI) with TIMI 0/1 flow in the infarct-related artery (IRA) and no significant bystander coronary artery disease on angiography, are randomised into one of three groups: PCI with adjunctive pharmacotherapy (intracoronary adenosine or SNP) or control (standard PCI). All receive Bivalirudin anticoagulation and thrombus aspiration. The primary outcome is infarct size (IS) (determined as a percentage of total left ventricular mass) measured by cardiac magnetic resonance imaging (CMRI) undertaken at 48 to 72 h post P-PCI. Secondary outcome measures include MVO (hypoenhancement within infarct core) on CMRI, angiographic markers of microvascular perfusion and MACE during 1-month follow-up. The study aims to recruit 240 patients (powered at 80% to detect a 5% absolute reduction in IS). DISCUSSION The REFLO-STEMI study has been designed to address the weaknesses of previous trials, which have collectively failed to demonstrate whether adjunctive pharmacotherapy with adenosine and/or SNP can reduce measures of myocardial injury (infarct size and MVO) and improve clinical outcome, despite good basic evidence that they have the potential to attenuate this process. The REFLO-STEMI study will be the most scientifically robust trial to date evaluating whether adjunctive therapy (intracoronary adenosine or SNP following thrombus aspiration) reduces CMRI measured IS and MVO in patients undergoing P-PCI within 6 h of onset of STEMI. TRIAL REGISTRATION Trial registered 20th November 2012: ClinicalTrials.gov Identifier NCT01747174.
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Affiliation(s)
- Sheraz A Nazir
- />Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK
| | - Jamal N Khan
- />Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK
| | - Islam Z Mahmoud
- />Department of Cardiovascular Imaging, Division of Imaging Sciences & Biomedical Engineering, Rayne Institute, BHF Excellence Centre, St Thomas’ Hospital, King’s College London, London, UK
| | - John P Greenwood
- />Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK
| | - Daniel J Blackman
- />Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK
| | - Vijay Kunadian
- />Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Martin Been
- />Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Keith R Abrams
- />Centre for Biostatistics & Genetic Epidemiology, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK
| | - Robert Wilcox
- />Faculty of Medicine & Health Sciences, Queen’s Medical Centre, Nottingham, UK
| | - AA Jennifer Adgey
- />Heart Centre, Royal Victoria Hospital, Belfast, Northern Ireland, UK
| | - Gerry P McCann
- />Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK
| | - Anthony H Gershlick
- />Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK
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Vecchio S, Varani E, Chechi T, Balducelli M, Vecchi G, Aquilina M, Ricci Lucchi G, Dal Monte A, Margheri M. Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management. World J Cardiol 2014; 6:381-392. [PMID: 24976910 PMCID: PMC4072828 DOI: 10.4330/wjc.v6.i6.381] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 03/26/2014] [Accepted: 04/11/2014] [Indexed: 02/06/2023] Open
Abstract
Acute ST-elevation myocardial infarction (STEMI) usually results from coronary atherosclerotic plaque disruption with superimposed thrombus formation. Detection of coronary thrombi is a poor prognostic indicator, which is mostly proportional to their size and composition. Particularly, intracoronary thrombi impair both epicardial blood flow and myocardial perfusion, by occluding major coronary arteries and causing distal embolization, respectively. Thus, although primary percutaneous coronary intervention is the preferred treatement strategy in STEMI setting, the associated use of adjunctive antithrombotic drugs and/or percutaneous thrombectomy is crucial to optimize therapy of STEMI patients, by improving either angiographical and clinical outcomes. This review article will focus on the prognostic significance of intracoronary thrombi and on current antithrombotic pharmacological and interventional strategies used in the setting of STEMI to manage thrombotic lesions.
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Ahn SG, Lee SH, Lee JH, Lee JW, Youn YJ, Ahn MS, Kim JY, Yoo BS, Yoon J, Choe KH, Tahk SJ. Efficacy of combination treatment with intracoronary abciximab and aspiration thrombectomy on myocardial perfusion in patients with ST-segment elevation myocardial infarction undergoing primary coronary stenting. Yonsei Med J 2014; 55:606-16. [PMID: 24719126 PMCID: PMC3990073 DOI: 10.3349/ymj.2014.55.3.606] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/25/2013] [Accepted: 10/02/2013] [Indexed: 12/19/2022] Open
Abstract
PURPOSE We aimed to investigate whether combination therapy using intracoronary (IC) abciximab and aspiration thrombectomy (AT) enhances myocardial perfusion compared to each treatment alone in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). MATERIALS AND METHODS We enrolled 40 patients with STEMI, who presented within 6 h of symptom onset and had Thrombolysis in MI flow 0/1 or a large angiographic thrombus burden (grade 3/4). Patients were randomly divided into 3 groups: 10 patients who received a bolus of IC abciximab (0.25 mg/kg); 10 patients who received only AT; and 20 patients who received both treatments. The index of microcirculatory resistance (IMR) was measured with a pressure sensor/thermistor-tipped guidewire following successful PCI. Microvascular obstruction (MVO) was assessed using cardiac magnetic resonance imaging on day 5. RESULTS IMR was lower in the combination group than in the IC abciximab group (23.5±7.4 U vs. 66.9±48.7 U, p=0.001) and tended to be lower than in the AT group, with barely missed significance (23.5±7.4 U vs. 37.2±26.1 U, p=0.07). MVO was observed less frequently in the combination group than in the IC abciximab group (18.8% vs. 88.9%, p=0.002) and tended to occur less frequently than in the AT group (18.8% vs. 66.7%, p=0.054). No difference of IMR and MVO was found between the IC abciximab and the AT group (66.9±48.7 U vs. 37.2±26.1 U, p=0.451 for IMR; 88.9% vs. 66.7%, p=0.525 for MVO, respectively). CONCLUSION Combination treatment using IC abciximab and AT may synergistically improve myocardial perfusion in patients with STEMI undergoing primary PCI (Trial Registration: clinicaltrials. gov Identifier: NCT01404507).
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Affiliation(s)
- Sung Gyun Ahn
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung-Hwan Lee
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji Hyun Lee
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jun-Won Lee
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Jin Youn
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Min-Soo Ahn
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jang-Young Kim
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung-Su Yoo
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Junghan Yoon
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyung-Hoon Choe
- Division of Cardiology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung-Jea Tahk
- Department of Cardiology, Ajou University Medical Center, Suwon, Korea
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Niccoli G, Cosentino N, Spaziani C, Minelli S, Fracassi F, Crea F. New strategies for the management of no-reflow after primary percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2014; 9:615-30. [DOI: 10.1586/erc.11.49] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Su Q, Li L, Liu Y. Short-term effect of verapamil on coronary no-reflow associated with percutaneous coronary intervention in patients with acute coronary syndrome: a systematic review and meta-analysis of randomized controlled trials. Clin Cardiol 2013; 36:E11-6. [PMID: 23749333 DOI: 10.1002/clc.22143] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/20/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND To evaluate the clinical efficacy and safety of intracoronary verapamil injection in the prevention and treatment of coronary no-reflow after percutaneous coronary intervention (PCI). HYPOTHESIS Intracoronary verapamil injection may be beneficial in preventing no-reflow/slow-flow after PCI. METHODS We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials database. Randomized trials comparing the efficacy and safety of intracoronary verapamil infusion vs control in patients with acute coronary syndrome (ACS) were included. Meta-analysis was performed by RevMan 5.0 software (Cochrane Collaboration, Copenhagen, Denmark) . RESULTS Seven trials involving 539 patients were included in the analysis. Verapamil treatment was significantly more effective in decreasing the incidence of no-reflow (risk ratio [RR]: 0.33; 95% confidence interval [CI]: 0.23 to 0.50) as well as reducing the corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) (weighted mean difference: -11.62; 95% CI: -16.04 to -7.21) and improving the TIMI myocardial perfusion grade (TMPG) (RR: 0.43; 95% CI: 0.29 to 0.64). Verapamil also reduced the 30-day wall motion index (WMI) compared to the control. Moreover, the procedure reduced the incidence of major adverse cardiac events (MACEs) in ACS patients during hospitalization (RR: 0.37; 95% CI: 0.17 to 0.80) and 2 months after PCI (RR: 0.56; 95% CI: 0.33 to 0.95). However, administration of verapamil did not provide an additional improvement of left ventricular ejection fraction regardless of the time that had passed post-PCI. CONCLUSIONS Intracoronary verapamil injection is beneficial in preventing no-reflow/slow-flow, reducing CTFC, improving TMPG, and lowering WMI. It is also likely to reduce the 2-month MACEs in ACS patients post-PCI.
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Affiliation(s)
- Qiang Su
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Guangxi Cardiovascular Institute, Nanning, China
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Aung Naing K, Li L, Su Q, Wu T. Adenosine and verapamil for no-reflow during primary percutaneous coronary intervention in people with acute myocardial infarction. Cochrane Database Syst Rev 2013:CD009503. [PMID: 23736949 DOI: 10.1002/14651858.cd009503.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PPCI) is the preferred treatment for ST segment elevation myocardial infarction. Although there is restoration of coronary flow after PPCI, impaired myocardial perfusion (known as no-reflow) is frequently observed, and is related to poor clinical outcomes. In order to overcome this phenomenon, drugs have been tried as adjunctive treatments to PPCI. Among them, verapamil and adenosine are two of the most promising drugs. There are no systematic reviews of these two drugs in people with acute myocardial infarction (AMI) undergoing PPCI. OBJECTIVES To study the impact of adenosine and verapamil on people with AMI who are undergoing PPCI. SEARCH METHODS We searched the following databases in February 2012: the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE, EMBASE, Web of Science and BIOSIS, China National Knowledge Infrastructure, Clinical Trials registers (Clinical Trials.gov, Current Controlled Trials, Australian & New Zealand Clinical Trials Registry, the WHO International Clinical Trials Registry Platform). We also handsearched the American Journal of Cardiology. SELECTION CRITERIA We selected randomised controlled trials (RCTs) where adenosine or verapamil was the primary intervention. Participants were individuals diagnosed with AMI who were undergoing PPCI. DATA COLLECTION AND ANALYSIS Two review authors collected studies and extracted data. Where necessary, we contacted the trial authors to obtain the relevant information. We calculated risk ratios (RRs), P values, and 95% confidence intervals (CIs) of dichotomous data. MAIN RESULTS We included 10 RCTs involving 939 participants in our review. Nine RCTs were associated with adenosine and one with verapamil. We considered the overall risk of bias of included studies to be moderate. There was no evidence that adenosine reduced short-term all-cause mortality (RR 0.61, 95% CI 0.23 to 1.61, P = 0.32), long-term all-cause mortality (RR 1.20, 95% CI 0.27 to 5.22, P = 0.81), short-term non-fatal myocardial infarction (RR 1.38, 95% 0.28 to 6.96, P = 0.69) or the incidence of angiographic no-reflow (TIMI flow grade < 3 after PPCI: RR 0.72, 95% CI 0.49 to 1.07, P = 0.11, and myocardial blush grade (MBG) 0 to 1 after PPCI: RR 0.96, 95% CI 0.76 to 1.22, P=0.75). But the incidence of adverse events with adenosine, such as bradycardia (RR 6.57, 95% CI 2.94 to 14.67, P<0.00001), hypotension (RR 11.43, 95% CI 2.75 to 47.57, P=0.0008) and atrioventricular (AV) block (RR 6.67, 95% CI 1.52 to 29.21, P=0.01) was significantly increased.Meta-analysis of verapamil as treatment for no-reflow during PPCI was not calculated due to lack of data. AUTHORS' CONCLUSIONS We found no evidence that adenosine and verapamil as treatments for no-reflow during PPCI can reduce all-cause mortality, non-fatal myocardial infarction or the incidence of angiographic no-reflow (TIMI flow grade < 3 and MBG 0 to1), but there was some evidence of increased adverse events. Further clinical research into adenosine and verapamil is needed because of the limited numbers of included trials and participants.
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Affiliation(s)
- Kyaw Aung Naing
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Niccoli G, Rigattieri S, De Vita MR, Valgimigli M, Corvo P, Fabbiocchi F, Romagnoli E, De Caterina AR, La Torre G, Lo Schiavo P, Tarantino F, Ferrari R, Tomai F, Olivares P, Cosentino N, D'Amario D, Leone AM, Porto I, Burzotta F, Trani C, Crea F. Open-label, randomized, placebo-controlled evaluation of intracoronary adenosine or nitroprusside after thrombus aspiration during primary percutaneous coronary intervention for the prevention of microvascular obstruction in acute myocardial infarction: the REOPEN-AMI study (Intracoronary Nitroprusside Versus Adenosine in Acute Myocardial Infarction). JACC Cardiovasc Interv 2013; 6:580-9. [PMID: 23683738 DOI: 10.1016/j.jcin.2013.02.009] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 02/15/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study sought to assess whether intracoronary adenosine or nitroprusside following thrombus aspiration (TA) is superior to TA alone for the prevention of microvascular obstruction (MVO) in ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). BACKGROUND MVO, due to its multifactorial pathogenesis, still occurs after TA in a sizeable portion of patients. METHODS We performed a placebo-controlled, randomized, open-label, blind-examination, multicenter trial. A total of 240 STEMI patients with Thrombolysis In Myocardial Infarction (TIMI) flow grade 0/1 were randomly allocated 1:1:1 to receive adenosine (n = 80), nitroprusside (n = 80), or saline (n = 80) given distal to the occluded site after TA. The primary endpoint was the incidence of ST-segment resolution (STR) >70% on surface electrocardiogram at 90 min after PCI. Secondary endpoints were angiographic MVO incidence (TIMI flow grade ≤2 or 3 with a myocardial blush grade <2) and major adverse cardiac event (MACE) rate at 30 days as a composite of cardiac death, myocardial infarction, target lesion revascularization, and heart failure requiring hospitalization. RESULTS STR >70% occurred in in 71% of adenosine-treated patients, in 54% of nitroprusside-treated patients, and in 51% of saline-treated patients (p = 0.009 and p = 0.75, respectively, vs. saline). Angiographic MVO occurred in 18% of adenosine-treated patients, in 24% of nitroprusside-treated patients, and in 30% of saline-treated patients (p = 0.06 and p = 0.37, respectively, vs. saline). MACE occurred in 10%, 14%, and 20% of patients, respectively (p = 0.08 and p = 0.29 vs. saline). CONCLUSIONS In STEMI patients treated by PCI and TA, the additional intracoronary administration of adenosine, but not that of nitroprusside, results in a significant improvement of MVO, as assessed by STR.
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Affiliation(s)
- Giampaolo Niccoli
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
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Schwartz BG, Kloner RA. Coronary no reflow. J Mol Cell Cardiol 2012; 52:873-82. [DOI: 10.1016/j.yjmcc.2011.06.009] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 06/10/2011] [Accepted: 06/13/2011] [Indexed: 10/18/2022]
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Wang J, Chen YD, Zhi G, Xu Y, Chen L, Liu HB, Zhou X, Tian F. Beneficial effect of adenosine on myocardial perfusion in patients treated with primary percutaneous coronary intervention for acute myocardial infarction. Clin Exp Pharmacol Physiol 2012; 39:247-52. [PMID: 22214231 DOI: 10.1111/j.1440-1681.2012.05668.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jing Wang
- Department of Cardiology; Beijing Anzhen Hospital; Capital Medical University; Beijing; China
| | - Yun-Dai Chen
- Department of Cardiology; Chinese People's Liberation Army General Hospital; Beijing; China
| | - Guang Zhi
- Department of Cardiology; Chinese People's Liberation Army General Hospital; Beijing; China
| | - Yong Xu
- Department of Cardiology; Chinese People's Liberation Army General Hospital; Beijing; China
| | - Lian Chen
- Department of Cardiology; Chinese People's Liberation Army General Hospital; Beijing; China
| | - Hong-Bin Liu
- Department of Cardiology; Chinese People's Liberation Army General Hospital; Beijing; China
| | - Xiao Zhou
- Department of Cardiology; Chinese People's Liberation Army General Hospital; Beijing; China
| | - Feng Tian
- Department of Cardiology; Chinese People's Liberation Army General Hospital; Beijing; China
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Lessick J, Abadi S, Agmon Y, Keidar Z, Carasso S, Aronson D, Ghersin E, Rispler S, Sebbag A, Israel O, Hammerman H, Roguin A. Multidetector computed tomography predictors of late ventricular remodeling and function after acute myocardial infarction. Eur J Radiol 2011; 81:2648-57. [PMID: 22209631 DOI: 10.1016/j.ejrad.2011.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 12/06/2011] [Accepted: 12/08/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite advent of rapid arterial revascularization as 1st line treatment for acute myocardial infarction (AMI), incomplete restoral of flow at the microvascular level remains a problem and is associated with adverse prognosis, including pathological ventricular remodeling. We aimed to study the association between multidetector row computed tomography (MDCT) perfusion defects and ventricular remodeling post-AMI. METHODS In a prospective study, 20 patients with ST-elevation AMI, treated by primary angioplasty, underwent arterial and late phase MDCT as well as radionuclide scans to study presence, size and severity of myocardial perfusion defects. Contrast echocardiography was performed at baseline and at 4 months follow-up to evaluate changes in myocardial function and remodeling. RESULTS Early defects (ED), late defects (LD) and late enhancement (LE) were detected in 15, 7 and 16 patients, respectively and radionuclide defects in 15 patients. The ED area (r=0.74), and LD area (r=0.72), and to a lesser extent LE area (r=0.62) correlated moderately well with SPECT summed rest score. By univariate analysis, follow-up end-systolic volume index and ejection fraction were both significantly related to ED and LD size and severity, but not to LE size or severity. By multivariate analysis, end-systolic volume index was best predicted by LD area (p<0.05) and ejection fraction by LD enhancement ratio. CONCLUSIONS LD size and severity on MDCT are most closely associated with pathological ventricular remodeling after AMI and may thus play a role in early identification and treatment of this condition.
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Affiliation(s)
- Jonathan Lessick
- Cardiology Department, Rambam Health Care Campus, Haaliya Street, Haifa, Israel; Technion-IIT, Haaliya Street, Haifa, Israel. j
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Matar F, Mroue J. The management of thrombotic lesions in the cardiac catheterization laboratory. J Cardiovasc Transl Res 2011; 5:52-61. [PMID: 22015675 DOI: 10.1007/s12265-011-9327-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 10/12/2011] [Indexed: 12/14/2022]
Abstract
Plaque rupture with superimposed thrombosis is the major mechanism of acute coronary syndromes. Although angiography underestimates the presence of thrombi, their detection is a poor prognostic indicator which is proportional to their size. Although emergent percutaneous coronary intervention (PCI) in the setting of ST elevation myocardial infarction (STEMI) and early PCI in the setting of unstable angina and non-STEMI were shown to be preferred strategies, the presence of angiographic thrombosis by virtue of causing micro and macro embolization can reduce the benefit of the intervention. Antiplatelet therapy especially using glycoprotein IIb/IIIa inhibitors reduces thrombus size, and improves myocardial perfusion and ventricular function. Routine manual aspiration prior to PCI in STEMI also improves myocardial flow and reduces distal embolization and improves survival. Distal embolic protection devices and mechanical thrombectomy do not have the same clinical benefits however, rheolytic thrombectomy may have a role in large vessels with a large thrombi.
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Affiliation(s)
- Fadi Matar
- Tampa General Hospital, Tampa, FL 33609, USA.
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Friedrich MG, Kim HW, Kim RJ. T2-weighted imaging to assess post-infarct myocardium at risk. JACC Cardiovasc Imaging 2011; 4:1014-21. [PMID: 21920341 PMCID: PMC3206638 DOI: 10.1016/j.jcmg.2011.07.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 07/13/2011] [Indexed: 11/16/2022]
Affiliation(s)
- Matthias G Friedrich
- CMR Centre, Montreal Heart Institute, Departmentof Cardiology, Université de Montreal,Montreal Quebec, Canada
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Butler MJ, Chan W, Taylor AJ, Dart AM, Duffy SJ. Management of the no-reflow phenomenon. Pharmacol Ther 2011; 132:72-85. [PMID: 21664376 DOI: 10.1016/j.pharmthera.2011.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 05/12/2011] [Indexed: 01/03/2023]
Abstract
The lack of reperfusion of myocardium after prolonged ischaemia that may occur despite opening of the infarct-related artery is termed "no reflow". No reflow or slow flow occurs in 3-4% of all percutaneous coronary interventions, and is most common after emergency revascularization for acute myocardial infarction. In this setting no reflow is reported to occur in 30% to 40% of interventions when defined by myocardial perfusion techniques such as myocardial contrast echocardiography. No reflow is clinically important as it is independently associated with increased occurrence of malignant arrhythmias, cardiac failure, as well as in-hospital and long-term mortality. Previously the no-reflow phenomenon has been difficult to treat effectively, but recent advances in the understanding of the pathophysiology of no reflow have led to several novel treatment strategies. These include prophylactic use of vasodilator therapies, mechanical devices, ischaemic postconditioning and potent platelet inhibitors. As no reflow is a multifactorial process, a combination of these treatments is more likely to be effective than any of these alone. In this review we discuss the pathophysiology of no reflow and present the numerous recent advances in therapy for this important clinical problem.
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Affiliation(s)
- Michelle J Butler
- Department of Cardiovascular Medicine, the Alfred Hospital, Melbourne, Australia
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Desmet W, Bogaert J, Dubois C, Sinnaeve P, Adriaenssens T, Pappas C, Ganame J, Dymarkowski S, Janssens S, Belmans A, Van de Werf F. High-dose intracoronary adenosine for myocardial salvage in patients with acute ST-segment elevation myocardial infarction. Eur Heart J 2010; 32:867-77. [PMID: 21196444 DOI: 10.1093/eurheartj/ehq492] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS Previous studies have suggested that intravenous administration of adenosine improves myocardial reperfusion and reduces infarct size in ST-elevation myocardial infarction (STEMI) patients. Intracoronary administration of adenosine has shown conflicting results. METHODS AND RESULTS In a prospective, single-centre, double-blind, placebo-controlled clinical study, we assessed whether selective intracoronary administration of adenosine distal to the occlusion site immediately before initial balloon inflation results in myocardial salvage and decreased microvascular obstruction (MVO) as assessed with cardiac magnetic resonance imaging (MRI). Using a combination of T(2)-weighted and contrast-enhanced sequences, myocardial salvage index (MSI) was defined as the percentage of the area at risk that did not become necrotic. We randomized 112 patients presenting with STEMI within 12 h from symptom onset to selective intracoronary administration of adenosine 4 mg or matching placebo. In 100/110 (91%) patients receiving study drug, MRI was performed on Days 2-3. No significant difference in MSI was found between adenosine- and placebo-treated patients: 41.3% (20.8, 66.7) vs. 47.8% (39.8, 60.9) [median (Q1, Q3)] (P = 0.52). The extent of MVO was comparable in both groups, with a trend favouring the placebo group: 2.4 g (0.0, 6.8) vs. 5.9 g (0.0, 12.8) after adenosine (P = 0.07). TIMI flow grade, TIMI frame count, myocardial blush grade, and ST-segment resolution after primary percutaneous coronary intervention were similar between groups. After 4 months, infarct size was similar in both treatment groups. CONCLUSION We found no evidence that selective high-dose intracoronary administration of adenosine distal to the occlusion site of the culprit lesion in STEMI patients results in incremental myocardial salvage or a decrease in microvascular obstruction.
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Affiliation(s)
- Walter Desmet
- Department of Cardiovascular Medicine, University Hospitals Leuven, Gasthuisberg, Herestraat 49, Leuven, Belgium.
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Jaffe R, Dick A, Strauss BH. Prevention and treatment of microvascular obstruction-related myocardial injury and coronary no-reflow following percutaneous coronary intervention: a systematic approach. JACC Cardiovasc Interv 2010; 3:695-704. [PMID: 20650430 DOI: 10.1016/j.jcin.2010.05.004] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 05/10/2010] [Accepted: 05/12/2010] [Indexed: 11/18/2022]
Abstract
Microvascular obstruction (MVO) commonly occurs following percutaneous coronary interventions (PCI), may lead to myocardial injury, and is an independent predictor of adverse outcome. Severe MVO may manifest angiographically as reduced flow in the patent upstream epicardial arteries, a situation that is termed "no-reflow." Microvascular obstruction can be broadly categorized according to the duration of myocardial ischemia preceding PCI. In "interventional MVO" (e.g., elective PCI), obstruction typically involves myocardium that was not exposed to acute ischemia before PCI. Conversely "reperfusion MVO" (e.g., primary PCI for acute myocardial infarction) occurs within a myocardial territory that was ischemic before the coronary intervention. Interventional and reperfusion MVO have distinct pathophysiological mechanisms and may require individualized therapeutic approaches. Interventional MVO is triggered predominantly by downstream embolization of atherosclerotic material from the epicardial vessel wall into the distal microvasculature. Reperfusion MVO results from both distal embolization and ischemia-reperfusion injury within the subtended ischemic tissue. Management of MVO and no-reflow may be targeted at different levels: the epicardial artery, microvasculature, and tissue. The aim of the present report is to advocate a systematic approach to prevention and treatment of MVO in different clinical settings. Randomized clinical trials have studied strategies for prevention of MVO and no-reflow; however, the efficacy of measures for reversing MVO once no-reflow has been demonstrated angiographically is unclear. New approaches for prevention and treatment of MVO will require a better understanding of intracellular cardioprotective pathways such as the blockade of the mitochondrial permeability transition pore.
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Affiliation(s)
- Ronen Jaffe
- Lady Davis Medical Center, Department of Cardiology, Haifa, Israel.
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Hale SL, Allison AC, Kloner RA. Diannexin reduces no-reflow after reperfusion in rabbits with large ischemic myocardial risk zones. Cardiovasc Ther 2010; 29:e42-52. [PMID: 20946319 DOI: 10.1111/j.1755-5922.2010.00223.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION AND AIMS In patients with ST-segment elevation myocardial infarction who receive percutaneous coronary intervention and stenting, a large zone with no-reflow is associated with adverse outcomes. During myocardial ischemia/reperfusion, phosphatidylserine (PS) translocates to the surface of endothelial cells triggering attachment of platelets and leukocytes, thus impairing microvascular blood flow. Diannexin, a recombinant dimer of the endogenous human annexin V protein, binds PS and thus inhibits the adverse effects of PS. It has been shown to attenuate postischemic reperfusion injury in several experimental models. We speculated that Diannexin would reduce no-reflow in the heart after coronary artery occlusion (CAO) and reperfusion. Rabbits received: (1) Diannexin 5 min pre-CAO (diannexin pre ischemia [DPI], 400 μg/kg, n = 17), or (2) Diannexin 5 min pre-coronary reperfusion (diannexin pre reperfusion [DPR], 400 μg/kg, n = 20), or (3) saline (Cont, n = 18), with 30 min CAO and 3 h reperfusion. In a secondary analysis, rabbits were divided into two groups based on the overall average risk zone size of 29% of the left ventricle (LV): small (<29% of LV) and large (>29% of LV). RESULTS Overall, risk zones and infarct size, and the no-reflow zone were similar in all groups. In hearts with large risk zones the no-reflow area was significantly smaller in both drug-treated groups (DPI, 22 ± 5% and DPR, 22 ± 3% vs. control 40 ± 3%, P < 0.006), the hemorrhagic areas were significantly smaller, and infarct size was reduced at the P < 0.06 level compared with control. In animals with small risk zones there were no significant differences. Diannexin treatment did not affect hemodynamics or LV function. CONCLUSION Diannexin was cardioprotective in rabbits with a severe ischemic insult. This is important, because large infarcts accompanied by no-reflow in humans are associated with increased complications. In animals with small risk zones, no significant drug effect was observed.
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Affiliation(s)
- Sharon L Hale
- The Heart Institute of Good Samaritan Hospital, Los Angeles, CA 90017, USA.
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Niccoli G, Marino M, Spaziani C, Crea F. Prevention and treatment of no-reflow. ACTA ACUST UNITED AC 2010; 12:81-91. [DOI: 10.3109/17482941.2010.498919] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Sboros V, Tang MX. The assessment of microvascular flow and tissue perfusion using ultrasound imaging. Proc Inst Mech Eng H 2010; 224:273-90. [PMID: 20349819 DOI: 10.1243/09544119jeim621] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Imaging microvascular flow is of diagnostic value for a wide range of diseases including cancer, inflammation, and cardiovascular disease. The introduction of microbubbles as ultrasound contrast agents offers significant signal enhancement to the otherwise weakly scattered signal from blood in the circulation. Microbubbles provide maximum impedance mismatch, but are not linear scatterers. Their complex response to ultrasound has generated research on both their behaviour and their scattered-signal processing. Nearly 20 years ago signal processing started with simple spectral filtering of harmonics showing contrast-enhanced images. More recent pulse encoding techniques have achieved good cancellation of tissue echoes. The good quality contrast-only images enabled ultrasound contrast-imaging applications to be established in microvascular measurements in the liver and the myocardium. The field promises to advance the quantification of microvascular flow kinetics.
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Affiliation(s)
- V Sboros
- Medical Physics, University of Edinburgh, Edinburgh, UK.
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Devine SM, Gregg A, Figler H, McIntosh K, Urmaliya V, Linden J, Pouton CW, White PJ, Bottle SE, Scammells PJ. Synthesis and evaluation of new N6-substituted adenosine-5'-N-methylcarboxamides as A3 adenosine receptor agonists. Bioorg Med Chem 2010; 18:3078-87. [PMID: 20385496 DOI: 10.1016/j.bmc.2010.03.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 03/16/2010] [Accepted: 03/17/2010] [Indexed: 11/25/2022]
Abstract
A number of N(6)-substituted adenosine-5'-N-methylcarboxamides were synthesised and their pharmacology, in terms of their receptor affinity, selectivity and cardioprotective effects, were explored. The first series of compounds, 4a-4f and 5a-5f, showed modest receptor affinity for the A(3)AR with K(i) values in the low to mid muM range. However, the incorporation of a 4-(2-aminoethyl)-2,6-di-tert-butylphenol group in the N(6)-position (in compounds 4g and 5g) significantly improved the affinity with K(i) values of 30 and 9 nM, respectively. Improvements in affinity, as well as selectivity were seen when a functionalized linker was introduced. The N(6)-phenyl series, compounds 7a-7d, demonstrated low to mid nanomolar receptor affinities (K(i)=2.3-45.0 nM), with 7b displaying 109-fold selectivity for the A(3)AR (vs A(1)). The N(6)-benzyl series 9a-9c also proved to be potent and selective A(3)AR agonists and the longer chain length linker 13 was tolerated at the A(3)AR without abrogation of affinity or selectivity. Cardioprotection was demonstrated by a simulated ischaemia cell culture assay, whereby 7b, 7c, 9a, 9b and 9c all showed cardioprotective effects at 100 nM comparable or better than the benchmark A(3)AR agonist IB-MECA, but which were indistinguishable by statistical analysis. For example, compound 9c reduced cell death by 68.0+/-3.6%.
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Affiliation(s)
- Shane M Devine
- Medicinal Chemistry and Drug Action, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville VIC 3052, Australia
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Heusch G, Kleinbongard P, Böse D, Levkau B, Haude M, Schulz R, Erbel R. Coronary microembolization: from bedside to bench and back to bedside. Circulation 2009; 120:1822-36. [PMID: 19884481 DOI: 10.1161/circulationaha.109.888784] [Citation(s) in RCA: 321] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coronary microembolization from the erosion or rupture of a vulnerable atherosclerotic plaque occurs spontaneously in acute coronary syndromes and iatrogenically during percutaneous coronary interventions. Typical consequences of coronary microembolization are microinfarcts with an inflammatory response, contractile dysfunction, and reduced coronary reserve. Apart from transient elevations of creatine kinase and troponin, microemboli can be visualized by intracoronary Doppler and the resulting microinfarcts by late-enhancement nuclear magnetic resonance. Statins, antiplatelet agents, and coronary vasodilators protect against microembolization and microinfarction when started before percutaneous coronary interventions. Distal protection devices can retrieve atherothrombotic debris and prevent its embolization into the microcirculation, but their effect on clinical outcome has been disappointing so far, except for saphenous vein bypass grafts. Devices for aspiration of thrombi and thrombus-derived vasoconstrictor, thrombogenic, and inflammatory substances, however, reduce thrombus burden, improve perfusion, and provide protection in patients with acute myocardial infarction.
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Affiliation(s)
- Gerd Heusch
- Institut für Pathophysiologie, Universitätsklinikum Essen, Essen, Germany.
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Fokkema ML, Vlaar PJ, Vogelzang M, Gu YL, Kampinga MA, de Smet BJ, Jessurun GA, Anthonio RL, van den Heuvel AF, Tan ES, Zijlstra F. Effect of high-dose intracoronary adenosine administration during primary percutaneous coronary intervention in acute myocardial infarction: a randomized controlled trial. Circ Cardiovasc Interv 2009; 2:323-9. [PMID: 20031735 DOI: 10.1161/circinterventions.109.858977.109.858977] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction is frequently seen in patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention. Previous studies have suggested that the administration of intravenous adenosine resulted in an improvement of myocardial perfusion and a reduction in infarct size. Intracoronary adenosine (bolus of 30 to 60 microg) is a guideline-recommended therapy to improve myocardial reperfusion. The effect of intracoronary adenosine during primary percutaneous coronary intervention has not been investigated in a large randomized trial. METHODS AND RESULTS Patients presenting with acute ST-elevation myocardial infarction were randomized to 2 bolus injections of intracoronary adenosine (2 x 120 microg in 20 mL NaCl) or placebo (2 x 20 mL NaCl). The first bolus injection was given after thrombus aspiration and the second after stenting of the infarct-related artery. The primary end point was the incidence of residual ST-segment deviation <0.2 mV, 30 to 60 minutes after percutaneous coronary intervention. Secondary end points were ST-segment elevation resolution, myocardial blush grade, Thrombolysis in Myocardial Infarction flow on the angiogram after percutaneous coronary intervention, enzymatic infarct size, and clinical outcome at 30 days. A total of 448 patients were randomized to intracoronary adenosine (N=226) or placebo (N=222). The incidence of residual ST-segment deviation <0.2 mV did not differ between patients randomized to adenosine or placebo (46.2% versus 52.2%, P=NS). In addition, there were no significant differences in secondary outcome measures. CONCLUSIONS In this randomized placebo controlled trial enrolling 448 patients with ST-elevation myocardial infarction, administration of intracoronary adenosine after thrombus aspiration and after stenting of the infarct-related artery did not result in improved myocardial perfusion.
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Affiliation(s)
- Marieke L Fokkema
- Thoraxcenter, Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Niccoli G, Dʼamario D, Spaziani C, Cosentino N, Marino M, Rigattieri S, Schiavo PL, De Vita MR, Tarantino F, Bartorelli A, Fabbiocchi F, Prati F, Imola F, Valgimigli M, Ferrari R, Crea F. Randomized evaluation of intracoronary nitroprusside vs. adenosine after thrombus aspiration during primary percutaneous coronary intervention for the prevention of no-reflow in acute myocardial infarction: the REOPEN-AMI study protocol. J Cardiovasc Med (Hagerstown) 2009; 10:585-92. [DOI: 10.2459/jcm.0b013e32832b3571] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Patel RAG, Glover DK, Broisat A, Kabul HK, Ruiz M, Goodman NC, Kramer CM, Meerdink DJ, Linden J, Beller GA. Reduction in myocardial infarct size at 48 hours after brief intravenous infusion of ATL-146e, a highly selective adenosine A2A receptor agonist. Am J Physiol Heart Circ Physiol 2009; 297:H637-42. [PMID: 19502555 DOI: 10.1152/ajpheart.00705.2008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study was undertaken to determine whether the myocardial infarct-sparing effect of ATL-146e, a selective adenosine A(2A) receptor agonist, persists without a rebound effect for at least 48 h and to determine the optimal duration of ATL-146e treatment in anesthetized dogs. Reperfusion injury after myocardial infarction (MI) is associated with inflammation lasting 24-48 h that contributes to ongoing myocyte injury. We previously showed that an ATL-146e infusion, starting just before reperfusion, decreased inflammation and infarct size in dogs examined 2 h after MI without increasing coronary blood flow. In the present study, adult dogs underwent 90 min of left anterior descending coronary artery occlusion. Thirty minutes before reperfusion, ATL-146e (0.01 microg x kg(-1) x min(-1); n = 21) or vehicle (n = 12) was intravenously infused and continued for 2.5 h (protocol 1) or 24 h (protocol 2). At 48 h after reperfusion hearts were excised and assessed for histological risk area and infarct size. Infarct size based on triphenyltetrazolium chloride (TTC) staining as a percentage of risk area was significantly smaller in ATL-146e-treated vs. control dogs (16.7 +/- 3.7% vs. 33.3 +/- 6.2%, P < 0.05; protocol 1). ATL-146e reduced neutrophil accumulation into infarcted myocardium of ATL-146e-treated vs. control dogs (30 +/- 7 vs. 88 +/- 16 cells/high-power field, P < 0.002). ATL-146e infusion for 24 h (protocol 2) conferred no significant additional infarct size reduction compared with 2.5 h of infusion. A 2.5-h ATL-146e infusion initiated 30 min before reperfusion results in marked, persistent (48 h) reduction in infarct size as a percentage of risk area in dogs with a reduction in infarct zone neutrophil infiltration. No significant further benefit was seen with a 24-h infusion.
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Affiliation(s)
- Rajan A G Patel
- Cardiovascular Division, Department of Medicine, University of Virginia, Charlottesville, Virginia 22908, USA
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Microvascular damage prevention with thrombaspiration during primary percutaneous intervention in acute myocardial infarction. Coron Artery Dis 2008; 20:51-7. [PMID: 18997622 DOI: 10.1097/mca.0b013e328307efef] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite rapid and complete recanalization of infarct-related artery with percutaneous coronary intervention, microvascular integrity is not often preserved. Several mechanical devices have been proposed to prevent distal embolization, but the impact of these devices on myocardial perfusion remains controversial. AIM The aim of our study was to assess microvascular damage reduction with quantitative myocardial contrast perfusion echocardiography among patients with the first anterior acute myocardial infarction treated with thromboaspiration during percutaneous coronary intervention. METHODS Forty-two patients (57.4+/-10 years, 74% males) with first anterior acute myocardial infarction were randomized 1 : 1 to intracoronary thromboaspiration followed by stenting, or to a conventional strategy of stenting alone. Echocardiogram and quantitative myocardial contrast echocardiography were performed 7 days and 1 month later, respectively. Parameter A (reflecting myocardial blood volume), beta (reflecting velocity, myocardial blood flow), and product of A and beta as indicator of myocardial blood flow were analyzed. For each patient mean value of A, beta, and A x beta from all dysfunctional segments was calculated. RESULTS The study population was divided into two groups: thromboaspiration (group I, 19 patients) and stenting alone (group II, 23 patients). No difference was observed between the both groups in demographic, clinical, echocardiographic, and angiographic data. Parameter A and A x beta were significantly higher in group I than in group II: 8.58+/-2.54 versus 5.29+/-3.18 dB (P<0.001) and 5.29+/-3.73 versus 2.78+/-3.03 dB/s (P<0.001). Multivariate step-down regression analysis revealed that only thromboaspiration before stenting and lower maximum troponin I have been associated with viability preservation in infarcted region. CONCLUSION Thromboaspiration before stenting in patients with the first anterior myocardial infarction improves myocardial perfusion at the tissue level assessed by quantitative myocardial contrast echocardiography.
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Yang Z, Linden J, Berr SS, Kron IL, Beller GA, French BA. Timing of adenosine 2A receptor stimulation relative to reperfusion has differential effects on infarct size and cardiac function as assessed in mice by MRI. Am J Physiol Heart Circ Physiol 2008; 295:H2328-35. [PMID: 18849340 DOI: 10.1152/ajpheart.00091.2008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The activation of adenosine 2A receptors before reperfusion following coronary artery occlusion reduces infarct size and improves ejection fraction (EF). In this study, we examined the effects of delaying treatment with the adenosine 2A receptor agonist ATL146e (ATL) until 1 h postreperfusion. The infarct size and EF were serially assessed by gadolinium-diethylenetriaminepentaacetic acid-enhanced MRI in C57BL/6 mice at 1 and 24 h postreperfusion. The infarct size was also assessed by 2,3,5-triphenyltetrazolium chloride staining at 24 h. Mice were treated with ATL (10 microg/kg ip) either 2 min before reperfusion (early ATL) or 1 h postreperfusion (late ATL) following the 45-min coronary occlusion. The two methods used to assess infarct size at 24 h postreperfusion (MRI and 2,3,5-triphenyltetrazolium chloride) showed an excellent correlation (R=0.96). The risk region, determined at 24 h postreperfusion, was comparable between the control and ATL-treated groups. The infarct size by MRI at 1 versus 24 h postreperfusion was 25+/-1 vs. 26+/-1% of left ventricular mass (means+/-SE) in control mice, 16+/-2 versus 17+/-2% in early-ATL mice, and 24+/-2 versus 25+/-2% in late-ATL mice (intragroup, P=not significant; and intergroup, early ATL vs. control or late ATL, P<0.05). EF was reduced in control mice but was largely preserved between 1 and 24 h in both early-ATL and late-ATL mice (P<0.05). In conclusion, after coronary occlusion in mice, the extent of myocellular death due to ischemia-reperfusion injury is 95% complete within 1 h of reperfusion. The infarct size was significantly reduced by ATL when given just before reperfusion, but not 1 h postreperfusion. Either treatment window helped preserve the EF between 1 and 24 h postreperfusion.
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Affiliation(s)
- Zequan Yang
- Department of Surgery, University of Virginia, MR5 Bldg. Rm. 1219, Box 800759, 415 Lane Rd., Charlottesville, VA 22903, USA
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