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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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Pantea-Roșan LR, Bungau SG, Radu AF, Pantea VA, Moisi MI, Vesa CM, Behl T, Nechifor AC, Babes EE, Stoicescu M, Gitea D, Iovanovici DC, Bustea C. A Narrative Review of the Classical and Modern Diagnostic Methods of the No-Reflow Phenomenon. Diagnostics (Basel) 2022; 12:diagnostics12040932. [PMID: 35453980 PMCID: PMC9029120 DOI: 10.3390/diagnostics12040932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 02/06/2023] Open
Abstract
The incidence of the no-reflow (NR) phenomenon varies depending on the diagnostic criteria used. If just the angiographic criteria are considered (i.e., a degree of thrombolysis in myocardial infarction ≤2), it will be found that the incidence of NR is quite low; on the other hand, when the myocardial NR is taken into account (i.e., a decrease in the quality of myocardial reperfusion expressed by the degree of myocardial blush), the real incidence is higher. Thus, the early establishment of a diagnosis of NR and the administration of specific treatment can lead to its reversibility. Otherwise, regardless of the follow-up period, patients with NR have a poor prognosis. In the present work, we offer a comprehensive perspective on diagnostic tools for NR detection, for improving the global management of patients with arterial microvasculature damage, which is a topic of major interest in the cardiology field, due to its complexity and its link with severe clinical outcomes.
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Affiliation(s)
- Larisa Renata Pantea-Roșan
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Simona Gabriela Bungau
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
- Correspondence: (S.G.B.); (A.-F.R.)
| | - Andrei-Flavius Radu
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
- Correspondence: (S.G.B.); (A.-F.R.)
| | - Vlad Alin Pantea
- Department of Dental Medicine, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
| | - Mădălina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
| | - Tapan Behl
- Department of Pharmacology, Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India;
| | - Aurelia Cristina Nechifor
- Analytical Chemistry and Environmental Engineering Department, Polytechnic University of Bucharest, 011061 Bucharest, Romania;
| | - Elena Emilia Babes
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (L.R.P.-R.); (E.E.B.); (M.S.)
| | - Daniela Gitea
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
| | - Diana Carina Iovanovici
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania;
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.M.V.); (C.B.)
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Fabris E, Selvarajah A, Tavenier A, Hermanides R, Kedhi E, Sinagra G, van’t Hof A. Complementary Pharmacotherapy for STEMI Undergoing Primary PCI: An Evidence-Based Clinical Approach. Am J Cardiovasc Drugs 2022; 22:463-474. [PMID: 35316483 PMCID: PMC9468081 DOI: 10.1007/s40256-022-00531-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
Antithrombotic therapy is the cornerstone of pharmacological treatment in patients undergoing primary percutaneous coronary intervention (PCI). However, the acute management of ST elevation myocardial infarction (STEMI) patients includes therapy for pain relief and potential additional strategies for cardioprotection. The safety and efficacy of some commonly used treatments have been questioned by recent evidence. Indeed a concern about morphine use is the interaction between opioids and oral P2Y12 inhibitors; early beta-blocker treatment has shown conflicting results for the improvement of clinical outcomes; and supplemental oxygen therapy lacks benefit in patients without hypoxia and may be of potential harm. Other additional strategies remain disappointing; however, some treatments may be selectively used. Therefore, we intend to present a critical updated review of complementary pharmacotherapy for a modern treatment approach for STEMI patients undergoing primary PCI.
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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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Niu X, Zhang J, Bai M, Peng Y, Sun S, Zhang Z. Effect of intracoronary agents on the no-reflow phenomenon during primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction: a network meta-analysis. BMC Cardiovasc Disord 2018; 18:3. [PMID: 29320987 PMCID: PMC5763527 DOI: 10.1186/s12872-017-0722-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 11/28/2017] [Indexed: 02/06/2023] Open
Abstract
Background Despite the restoration of epicardial flow after primary percutaneous coronary intervention (PPCI), myocardial reperfusion remains impaired in a significant proportion of patients. We performed a network meta-analysis to assess the effect of 7 intracoronary agents (adenosine, anisodamine, diltiazem, nicorandil, nitroprusside, urapidil, and verapamil) on the no-reflow phenomenon in patients with ST-elevation myocardial infarction (STEMI) undergoing PPCI. Methods Database searches were conducted to identify randomized controlled trials (RCTs) comparing the 7 agents with each other or with standard PPCI. Outcome measures included thrombolysis in myocardial infarction flow grade (TFG), ST-segment resolution (STR), left ventricular ejection fraction (LVEF), major adverse cardiovascular events (MACEs), and adverse events. Results Forty-one RCTs involving 4069 patients were analyzed. The addition of anisodamine to standard PPCI for STEMI was associated with improved post-procedural TFG, more occurrences of STR, and improvement of LVEF. The cardioprotective effect of anisodamine conferred a MACE-free survival benefit. Additionally, nitroprusside was regarded as efficient in improving coronary flow and clinical outcomes. Compared with standard care, adenosine, nicorandil, and verapamil improved coronary flow but had no corresponding benefits regarding cardiac function and clinical outcomes. The ranking probability for the 7 treatment drugs showed that anisodamine consistently ranked the highest in efficacy outcomes (TFG < 3, STR, LVEF, and MACEs). No severe adverse events, such as hypotension and malignant arrhythmia, were observed in patients treated with anisodamine. Network meta-regression analysis showed that age, the time to reperfusion, and study follow-up did not affect the treatment effects. Conclusions The intracoronary administration of anisodamine appears to improve myocardial reperfusion, cardiac function, and clinical outcomes in patients with STEMI undergoing PPCI. Given the limited quality and quantity of the included studies, more rigorous RCTs are needed to verify the role of this inexpensive and well-tolerated regimen. Electronic supplementary material The online version of this article (10.1186/s12872-017-0722-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiaowei Niu
- The First School of Clinical Medicine, Lanzhou University, Tianshui South Road, No. 222, Lanzhou, Gansu, 730000, China
| | - Jingjing Zhang
- Baiyin Second People's Hospital, Gongyuan Road, No. 509, Baiyin, Gansu, 730900, China
| | - Ming Bai
- Department of Cardiology, the First Hospital of Lanzhou University, Donggang West Road, No. 1, Lanzhou, Gansu, 730000, China
| | - Yu Peng
- Department of Cardiology, the First Hospital of Lanzhou University, Donggang West Road, No. 1, Lanzhou, Gansu, 730000, China
| | - Shaobo Sun
- Key Lab of Prevention and Treatment for Chronic Disease, Gansu University of Chinese Medicine, Dingxi East Road, No. 35, Lanzhou, Gansu, 730000, China
| | - Zheng Zhang
- Department of Cardiology, the First Hospital of Lanzhou University, Donggang West Road, No. 1, Lanzhou, Gansu, 730000, China.
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Luo H, Fan Z, Xiang D, Jiang Z, Zhang W, Gao L, Feng C. The protective effect of umbelliferone ameliorates myocardial injury following ischemia‑reperfusion in the rat through suppression NLRP3 inflammasome and upregulating the PPAR-γ. Mol Med Rep 2017; 17:3404-3410. [PMID: 29257247 DOI: 10.3892/mmr.2017.8208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 10/02/2017] [Indexed: 11/05/2022] Open
Abstract
The present study investigated whether the protective effect of umbelliferone could regulate myocardial injury following ischemia‑reperfusion and improve mitochondrial respiratory function, thereby relieving myocardial injury following ischemia‑reperfusion in rats. In the present study, the extent of inflammation and oxidative stress were analyzed using ELISA. Western blot analysis was employed to investigate the protein expression levels of the PYD domains‑containing protein 3 (NLRP3) inflammasome and peroxisome proliferator‑activated receptor-γ (PPAR‑γ). Compared with the myocardial injury following ischemia‑reperfusion group, umbelliferone significantly prevented myocardial injury, inhibited oxidative stress markers (superoxide dismutase and malondialdehyde), reduced inflammation (tumor necrosis factor‑α and interleukin‑6) and myocardial apoptosis levels (caspase‑3/9 and apoptosis regular B‑cell lymphoma‑2‑associated X protein) in the myocardial injury following ischemia‑reperfusion group of rats. Umbelliferone treatment also suppressed NACHT, LRR and NLRP3 inflammasome activation and induced PPAR‑γ expression. The results of the present study suggested that the protective effect of umbelliferone may ameliorate myocardial injury following ischemia‑reperfusion in the rat through the suppression of the NLRP3 inflammasome and upregulating PPAR‑γ expression.
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Affiliation(s)
- Hongbo Luo
- Department of Cardiovascular Surgery, The People's Hospital of Guizhou, Guiyang, Guizhou 550002, P.R. China
| | - Zhengke Fan
- Department of Cardiothoracic Surgery, The First People's Hospital, Bijie, Guizhou 551700, P.R. China
| | - Daokang Xiang
- Department of Cardiovascular Surgery, The People's Hospital of Guizhou, Guiyang, Guizhou 550002, P.R. China
| | - Zhenwei Jiang
- Department of Cardiovascular Surgery, The People's Hospital of Guizhou, Guiyang, Guizhou 550002, P.R. China
| | - Wenbin Zhang
- Department of Cardiovascular Surgery, The People's Hospital of Guizhou, Guiyang, Guizhou 550002, P.R. China
| | - Lufang Gao
- Department of Cardiovascular Surgery, The People's Hospital of Guizhou, Guiyang, Guizhou 550002, P.R. China
| | - Chao Feng
- Department of Cardiovascular Surgery, The People's Hospital of Guizhou, Guiyang, Guizhou 550002, P.R. China
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Rathod KS, Hamshere S, Khambata RS, Andiapen M, Westwood M, Mathur A, Ahluwalia A, Jones DA. Combined analysis of the safety of intra-coronary drug delivery during primary percutaneous coronary intervention for acute myocardial infarction: A study of three clinical trials. JRSM Cardiovasc Dis 2017; 6:2048004017725988. [PMID: 29104752 PMCID: PMC5562348 DOI: 10.1177/2048004017725988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 12/22/2022] Open
Abstract
Background The local injection of novel cardioprotective study drugs prior to percutaneous coronary intervention could cause embolisation of thrombus, resulting in increased reperfusion injury and subsequent infarct size. The aim of this study was to assess the safety of the delivery of an intracoronary therapy delivered during primary percutaneous coronary intervention for acute myocardial infarction prior to the re-establishment of thrombolysis in myocardial infarction III flow. Methods One hundred sixty-seven patients with acute myocardial infarction successfully reperfused through primary percutaneous coronary intervention and undergoing Cardiac MRI within the first week after reperfusion were studied. Patients either underwent the delivery of an intracoronary agent (IMP or placebo) prior to balloon dilatation (n = 80) or standard primary percutaneous coronary intervention procedure (n = 117). Results Baseline characteristics were similar between the two groups. There were a similar number of successful procedures (IC IMP 75 (93.8%) vs. No IMP 114, (97.4%), p = 0.374), rates of no-reflow (IC IMP 1 (1.3%) vs. No IMP 2 (1.7%), p = 0.99) and levels of ST segment resolution (88.5% IC IMP vs. No IC IMP 87.0%, p = 0.669) between the two groups. Similar levels of microvascular obstruction were seen between the two groups with a trend to reduced infarct size, and improved ejection fractions in the IMP group. Lower MACE rates were seen in the IMP group. Conclusion The local intracoronary infusion of potential cardioprotective agents prior to the restoration of TIMI flow in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction appears to be safe and does not increase microvascular damage. This route should be considered when testing novel cardioprotective agents.
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Affiliation(s)
- Krishnaraj S Rathod
- William Harvey Research Institute, Barts & The London Medical School, Queen Mary University of London, London, UK.,Department of Cardiology, Barts Health NHS Trust, London, UK
| | | | - Rayomand S Khambata
- William Harvey Research Institute, Barts & The London Medical School, Queen Mary University of London, London, UK
| | - Mervyn Andiapen
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Mark Westwood
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Anthony Mathur
- William Harvey Research Institute, Barts & The London Medical School, Queen Mary University of London, London, UK.,Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Amrita Ahluwalia
- William Harvey Research Institute, Barts & The London Medical School, Queen Mary University of London, London, UK
| | - Daniel A Jones
- William Harvey Research Institute, Barts & The London Medical School, Queen Mary University of London, London, UK.,Department of Cardiology, Barts Health NHS Trust, London, UK
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Li Y, Li Q, Li F, Zong M, Miao G, Yang X, Tong Z, Zhang J. Evaluation of Short- and Long-Term Efficacy of Combined Intracoronary Administration of High-Dose Adenosine and Tirofiban during Primary Percutaneous Coronary Intervention. ACTA CARDIOLOGICA SINICA 2016; 32:640-648. [PMID: 27899850 DOI: 10.6515/acs20151013i] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND To assess the influence of combined intracoronary application of high-dose adenosine and tirofiban in primary percutaneous coronary intervention (PCI) on clinical events and cardiac function. METHODS Our study evaluated consecutive patients with acute ST-segment elevation myocardial infarction undergoing primary PCI, who were randomly divided into adenosine group (n = 130) and control group (n = 128). Combined with thrombus aspiration and then intracoronary tirofiban, the adenosine group received intracoronary adenosine (2 mg) through the aspiration catheter 2 times. After thrombus aspiration and stenting of the infarct- related artery, the control group received placebo. The primary endpoint of our investigation was major adverse cardiac events (MACE) at the 1-year and 3-year marks. The secondary endpoint comprised left ventricular remodeling (LVR) at 6 months, myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) flow grade and corrected TIMI frame count (CTFC) after PCI. RESULTS Our study found that TIMI flow grade post-PCI did not differ significantly between the 2 groups, while CTFC favored the adenosine-treated patients (21.6 ± 6.5 vs. 25.1 ± 7.8, p = 0.001). Although the adenosine group achieved a higher rate of MBG 3 (45.1% vs. 32.0%, p = 0.035) and MBG 2-3 (76.2% vs. 62.3%, p = 0.018) than the control group, the incidences of MACE at 1 year (20.0% vs. 25.0%, p = 0.373) and 3 years (26.9% vs. 32.0%, p = 0.413) were comparable. LVR occurred in 23.1% (27/117) of adenosine-treated patients and in 29.8% (43/114) of the controls (p = 0.296). CONCLUSIONS Intracoronary administration of high-dose adenosine combined with intracoronary tirofiban and thrombus aspiration may further improve myocardial perfusion after primary PCI.
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Affiliation(s)
- Yanbing Li
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qiang Li
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Feiou Li
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Min Zong
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Guobin Miao
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinchun Yang
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zichuan Tong
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jianjun Zhang
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Yetgin T, Uitterdijk A, Te Lintel Hekkert M, Merkus D, Krabbendam-Peters I, van Beusekom HMM, Falotico R, Serruys PW, Manintveld OC, van Geuns RJM, Zijlstra F, Duncker DJ. Limitation of Infarct Size and No-Reflow by Intracoronary Adenosine Depends Critically on Dose and Duration. JACC Cardiovasc Interv 2016; 8:1990-1999. [PMID: 26738671 DOI: 10.1016/j.jcin.2015.08.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 08/14/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES In the absence of effective clinical pharmacotherapy for prevention of reperfusion-mediated injury, this study re-evaluated the effects of intracoronary adenosine on infarct size and no-reflow in a porcine model of acute myocardial infarction using clinical bolus and experimental high-dose infusion regimens. BACKGROUND Despite the clear cardioprotective effects of adenosine, when administered prior to ischemia, studies on cardioprotection by adenosine when administered at reperfusion have yielded contradictory results in both pre-clinical and clinical settings. METHODS Swine (54 ± 1 kg) were subjected to a 45-min mid-left anterior descending artery occlusion followed by 2 h of reperfusion. In protocol A, an intracoronary bolus of 3 mg adenosine injected over 1 min (n = 5) or saline (n = 10) was administered at reperfusion. In protocol B, an intracoronary infusion of 50 μg/kg/min adenosine (n = 15) or saline (n = 21) was administered starting 5 min prior to reperfusion and continued throughout the 2-h reperfusion period. RESULTS In protocol A, area-at-risk, infarct size, and no-reflow were similar between groups. In protocol B, risk zones were similar, but administration of adenosine resulted in significant reductions in infarct size from 59 ± 3% of the area-at-risk in control swine to 46 ± 4% (p = 0.02), and no-reflow from 49 ± 6% of the infarct area to 26 ± 6% (p = 0.03). CONCLUSIONS During reperfusion, intracoronary adenosine can limit infarct size and no-reflow in a porcine model of acute myocardial infarction. However, protection was only observed when adenosine was administered via prolonged high-dose infusion, and not via short-acting bolus injection. These findings warrant reconsideration of adenosine as an adjuvant therapy during early reperfusion.
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Affiliation(s)
- Tuncay Yetgin
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - André Uitterdijk
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Maaike Te Lintel Hekkert
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Daphne Merkus
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ilona Krabbendam-Peters
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Heleen M M van Beusekom
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Patrick W Serruys
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Robert-Jan M van Geuns
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - Dirk J Duncker
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands.
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Nazir SA, McCann GP, Greenwood JP, Kunadian V, Khan JN, Mahmoud IZ, Blackman DJ, Been M, Abrams KR, Shipley L, Wilcox R, Adgey AAJ, Gershlick AH. Strategies to attenuate micro-vascular obstruction during P-PCI: the randomized reperfusion facilitated by local adjunctive therapy in ST-elevation myocardial infarction trial. Eur Heart J 2016; 37:1910-9. [PMID: 27147610 PMCID: PMC4917746 DOI: 10.1093/eurheartj/ehw136] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 03/09/2016] [Indexed: 11/16/2022] Open
Abstract
Background Microvascular obstruction (MVO) following primary percutaneous coronary intervention (PPCI) treatment of ST-segment elevation myocardial infarction (STEMI) contributes to infarct expansion, left ventricular (LV) remodelling, and worse clinical outcomes. The REFLO-STEMI trial tested whether intra-coronary (IC) high-dose adenosine or sodium nitroprusside (SNP) reduce infarct size and/or MVO determined by cardiac magnetic resonance (CMR). Methods and results REFLO-STEMI, a prospective, open-label, multi-centre trial with blinded endpoints, randomized (1:1:1) 247 STEMI patients with single vessel disease presenting within 6 h of symptom onset to IC adenosine (2–3 mg total) or SNP (500 μg total) immediately following thrombectomy and again following stenting, or to standard PPCI. The primary endpoint was infarct size % LV mass (%LVM) on CMR undertaken 24–96 h after PPCI (n = 197). Clinical follow-up was to 6 months. There was no significant difference in infarct size (%LVM, median, interquartile range, IQR) between adenosine (10.1, 4.7–16.2), SNP (10.0, 4.2–15.8), and control (8.3, 1.9–14.0), P = 0.062 and P = 0.160, respectively, vs. control. MVO (% LVM, median, IQR) was similar across groups (1.0, 0.0–3.7, P = 0.205 and 0.6, 0.0–2.4, P = 0.244 for adenosine and SNP, respectively, vs. control 0.3, 0.0–2.8). On per-protocol analysis, infarct size (%LV mass, 12.0 vs. 8.3, P = 0.031), major adverse cardiac events (hazard ratio, HR, 5.39 [1.18–24.60], P = 0.04) at 30 days and 6 months (HR 6.53 [1.46–29.2], P = 0.01) were increased and ejection fraction reduced (42.5 ± 7.2% vs. 45.7 ± 8.0%, P = 0.027) in adenosine-treated patients compared with control. Conclusions High-dose IC adenosine and SNP during PPCI did not reduce infarct size or MVO measured by CMR. Furthermore, adenosine may adversely affect mid-term clinical outcome. Clinical Trial registration ClinicalTrials.gov Identifier: NCT01747174; https://clinicaltrials.gov/ct2/show/NCT01747174
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Affiliation(s)
- Sheraz A Nazir
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Vijay Kunadian
- Institute of Cellular Medicine, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jamal N Khan
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, 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
| | - Daniel J Blackman
- Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin Been
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Keith R Abrams
- Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK
| | - Lorraine Shipley
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Robert Wilcox
- Faculty of Medicine & Health Sciences, Queen's Medical Centre, Nottingham, UK
| | | | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
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11
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Lee WC, Chen SM, Liu CF, Chen CJ, Chung WJ, Hsueh SK, Tsai TH, Fang HY, Yip HK, Hang CL. Early Administration of Intracoronary Nitroprusside Compared with Thrombus Aspiration in Myocardial Perfusion for Acute Myocardial Infarction: A 3-Year Clinical Follow-Up Study. ACTA CARDIOLOGICA SINICA 2016; 31:373-80. [PMID: 27122896 DOI: 10.6515/acs20150515a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Intracoronary nitroprusside and thrombus aspiration have been demonstrated to improve myocardial perfusion during percutaneous coronary interventions (PCI) for ST-segment elevation acute myocardial infarction (STEMI) However, no long-term clinical studies have been performed comparing these approaches. METHODS A single medical center retrospective study was conducted to evaluate the effects of intracoronary nitroprusside administration before slow/no-reflow phenomena versus thrombus aspiration during primary PCI. Forty-three consecutive patients with STEMI were enrolled in the intracoronary nitroprusside treatment group. One hundred twenty-four consecutive STEMI patients who received thrombus aspiration were enrolled; ninety-seven consecutive STEMI patients who did not receive either thrombus aspiration or intracoronary nitroprusside treatment were enrolled and served as control subjects. Patients with cardiogenic shock, who had received platelet glycoprotein IIb/IIIa inhibitor, or intra-aortic balloon pump insertion were excluded. Thrombolysis in Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count and TIMI myocardial perfusion grade (TMPG) were assessed prior to and following PCI by two independent cardiologists blinded to the procedures. The rate of major adverse cardiac events (MACE) at 30 days, 1 year, and 3 years after study enrollment as a composite of recurrent myocardial infarction, target-vessel revascularization, and cardiac death were recorded. RESULTS The control group had a significantly lower pre-PCI TIMI flow (≤ 1; 49.5% vs. 69.8% vs. 77.4%; p = < 0.001) compared with the nitroprusside and thrombus aspiration groups. The thrombus aspiration group had a significantly higher pre-PCI thrombus score (> 4; 98.4% vs. 88.4% vs. 74.3%; p = < 0.001) and post-PCI TMPG (3; 39.5% vs. 16.3% vs. 20.6%; p = 0.001) compared with the nitroprusside and control groups. No significant differences were noted in the post-PCI thrombus score, 30-day, 1-year and 3-year MACE rate, and Kaplan-Meier curve among 3 groups of patients. CONCLUSIONS Although thrombus aspiration provided improved TMPG compared with early administration of intracoronary nitroprusside and neither of both during primary PCI, it did not have a significant impact on 30-day, 1-year and 3-year MACE rate. KEY WORDS Acute myocardial infarction; Intracoronary nitroprusside; Thrombus aspiration.
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Affiliation(s)
- Wei-Chieh Lee
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
| | - Shyh-Ming Chen
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
| | - Chu-Feng Liu
- Chang Gung University College of Medicine; ; Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chien-Jen Chen
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
| | - Wen-Jung Chung
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
| | - Shu-Kai Hsueh
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
| | - Tzu-Hsien Tsai
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
| | - Hsiu-Yu Fang
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
| | - Hon-Kan Yip
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
| | - Chi-Ling Hang
- Section of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital; ; Chang Gung University College of Medicine
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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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Kizilirmak F, Gunes HM, Demir GG, Gokdeniz T, Guler E, Cakal B, Omaygenç MO, Yılmaz F, Savur U, Barutcu I. Impact of Intracoronary Adenosine on Myonecrosis in Patients with Unstable Angina Pectoris Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2015; 29:519-526. [DOI: 10.1007/s10557-015-6631-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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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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Garcia-Dorado D, García-del-Blanco B, Otaegui I, Rodríguez-Palomares J, Pineda V, Gimeno F, Ruiz-Salmerón R, Elizaga J, Evangelista A, Fernandez-Avilés F, San-Román A, Ferreira-González I. Intracoronary injection of adenosine before reperfusion in patients with ST-segment elevation myocardial infarction: A randomized controlled clinical trial. Int J Cardiol 2014; 177:935-41. [DOI: 10.1016/j.ijcard.2014.09.203] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 09/16/2014] [Accepted: 09/30/2014] [Indexed: 12/12/2022]
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Kleinbongard P, Heusch G. Extracellular signalling molecules in the ischaemic/reperfused heart - druggable and translatable for cardioprotection? Br J Pharmacol 2014; 172:2010-25. [PMID: 25204973 DOI: 10.1111/bph.12902] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 08/21/2014] [Accepted: 08/29/2014] [Indexed: 12/28/2022] Open
Abstract
In patients with acute myocardial infarction, timely reperfusion is essential to limit infarct size. However, reperfusion also adds to myocardial injury. Brief episodes of ischaemia/reperfusion in the myocardium or on organ remote from the heart, before or shortly after sustained myocardial ischaemia effectively reduce infarct size, provided there is eventual reperfusion. Such conditioning phenomena have been established in many experimental studies and also translated to humans. The underlying signal transduction, that is the molecular identity of triggers, mediators and effectors, is not clear yet in detail, but several extracellular signalling molecules, such as adenosine, bradykinin and opioids, have been identified to contribute to cardioprotection by conditioning manoeuvres. Several trials have attempted the translation of cardioprotection by such autacoids into a clinical scenario of myocardial ischaemia and reperfusion. Adenosine and its selective agonists reduced infarct size in a few studies, but this benefit was not translated into improved clinical outcome. All studies with bradykinin or drugs which increase bradykinin's bioavailability reported reduced infarct size and some of them also improved clinical outcome. Synthetic opioid agonists did not result in a robust infarct size reduction, but this failure of translation may relate to the cardioprotective properties of the underlying anaesthesia per se or of the comparator drugs. The translation of findings in healthy, young animals with acute coronary occlusion/reperfusion to patients of older age, with a variety of co-morbidities and co-medications, suffering from different scenarios of myocardial ischaemia/reperfusion remains a challenge.
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Affiliation(s)
- P Kleinbongard
- Institute for Pathophysiology, West German Heart and Vascular Center, University School of Medicine Essen, Essen, Germany
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Atorvastatin Post-Conditioning Attenuates Myocardial Ischemia Reperfusion Injury via Inhibiting Endoplasmic Reticulum Stress–Related Apoptosis. Shock 2014; 42:365-71. [DOI: 10.1097/shk.0000000000000224] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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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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Buelna-Chontal M, Guevara-Chávez JG, Silva-Palacios A, Medina-Campos ON, Pedraza-Chaverri J, Zazueta C. Nrf2-regulated antioxidant response is activated by protein kinase C in postconditioned rat hearts. Free Radic Biol Med 2014; 74:145-56. [PMID: 24992834 DOI: 10.1016/j.freeradbiomed.2014.06.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/19/2014] [Accepted: 06/24/2014] [Indexed: 12/21/2022]
Abstract
Postconditioning (PostC) activates endogenous protective mechanisms that contend against reperfusion injury. Nevertheless, although PostC efficiency in both experimental studies and clinical trials has been demonstrated, a complete picture of the interacting mechanisms, particularly the relationship between kinase signaling and redox maintenance, is still lacking. To unravel such association, in this work we focus on the participation of protein kinase C (PKC) and the transcription factor nuclear factor E2-related factor 2 (Nrf2) in the cardioprotective response elicited by PostC. PostC was performed in an in vivo rat model by applying three repetitive cycles of ischemia and reperfusion (10 s each), followed by evaluation of heart function and infarct size measurements. PKC activation and Nrf2 phosphorylation were evaluated after 10 min of reperfusion, whereas Nrf2 activity and the content and activities of Nrf2-regulated antioxidant proteins were evaluated after 60 min of reperfusion in PostC hearts. Maintenance of heart function and diminution in infarct size concurred with PKC activation and Nrf2 phosphorylation. PKC inhibition diminished Nrf2 phosphorylation and transcriptional activity in association with diminished levels and activities of Nrf2-regulated antioxidant proteins. In conclusion, this study proposes that the novel pathway PKC/Nrf2 participates in the long-term protective mechanisms induced by PostC application by maintaining the antioxidant defense system.
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Affiliation(s)
- Mabel Buelna-Chontal
- Department of Cardiovascular Biomedicine, National Institute of Cardiology I. Ch., Mexico City 14080, DF, Mexico
| | | | - Alejandro Silva-Palacios
- Department of Cardiovascular Biomedicine, National Institute of Cardiology I. Ch., Mexico City 14080, DF, Mexico
| | - Omar-Noel Medina-Campos
- Biology Department, Faculty of Chemistry, National Autonomous University of Mexico, Mexico City, DF, Mexico
| | - José Pedraza-Chaverri
- Biology Department, Faculty of Chemistry, National Autonomous University of Mexico, Mexico City, DF, Mexico
| | - Cecilia Zazueta
- Department of Cardiovascular Biomedicine, National Institute of Cardiology I. Ch., Mexico City 14080, DF, Mexico.
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The impact of ischemia-reperfusion injury on the effectiveness of primary angioplasty in ST-segment elevation myocardial infarction. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2013; 9:275-81. [PMID: 24570732 PMCID: PMC3915986 DOI: 10.5114/pwki.2013.37509] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 07/12/2013] [Accepted: 08/16/2013] [Indexed: 01/16/2023] Open
Abstract
The most effective method of reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (PCI), assisted by aspiration thrombectomy and administration of antiplatelet agents and anticoagulants. However, effective restoration of blood flow in the infarct-related artery may paradoxically result in further damage to the heart muscle. This phenomenon, called ischemia-reperfusion injury (IRI), can significantly reduce the beneficial effects of reperfusion therapy. The rapid restoration of blood flow to the previously ischemic area causes a number of pathophysiological mechanisms leading to increased necrosis of myocytes still viable at the end of the ischemic period. It has been postulated that there are several strategies that can reduce damage to the heart muscle. Attempts to translate the results of experimental trials has been disappointing. More recently, however, some of the clinical benefits of ischemic postconditioning in which reperfusion in patients with STEMI who are undergoing PCI is interrupted with short episodes of ischemia were demonstrated. This renewed the interest in the reperfusion phase as a target for cardioprotective therapy. Research in this field has also been reinforced by the discovery of new potential targets for treatment that protects against IRI, such as the kinase pathway to protect against damage (reperfusion injury salvage kinases – RISK) and mitochondrial permeability transition pore. It seems that these findings will help to develop strategies that will improve the efficiency of mechanical reperfusion and may translate into long-term clinical effects.
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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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25
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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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A single-center prospective randomized controlled trial evaluating the safety and efficacy of IntraCoronary Erythropoietin delivery BEfore Reperfusion: Gauging infarct size in patients with acute ST-segment elevation myocardial infarction. Study design and rationale of the ‘ICEBERG Trial’11Trial registration: http://www.ClinicalTrials.gov identifier: NCT01538771. Contemp Clin Trials 2013; 35:145-50. [DOI: 10.1016/j.cct.2013.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 03/05/2013] [Accepted: 03/08/2013] [Indexed: 11/19/2022]
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Guo AQ, Sheng L, Lei X, Shu W. Pharmacological and physical prevention and treatment of no-reflow after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. J Int Med Res 2013; 41:537-47. [PMID: 23628920 DOI: 10.1177/0300060513479859] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
After successful primary percutaneous coronary intervention in ST-segment elevation myocardial infarction, adequate myocardial reperfusion is not achieved in up to 50% of patients. This phenomenon of no-reflow is associated with a poor in-hospital and long-term prognosis. Four main factors are thought to contribute to the occurrence of no-reflow: ischaemic injury; reperfusion injury; distal embolization; susceptibility of the microcirculation to injury. This review evaluates the literature, and in particular the clinical trials, concerned with pharmacological and physical methods for prevention and treatment of no-reflow. A number of drugs may improve no-reflow experimentally and clinically, but some have not yet been associated with conclusive improvements in clinical outcome. The complex interacting factors in no-reflow make it unlikely that any single agent will be effective for all patients. Confirmed methods known to be beneficial in the prevention of no-reflow (such as aspirin therapy, chronic statin therapy, blood glucose control, thrombus aspiration in patients with a high thrombus burden and ischaemic preconditioning) should be offered to patients as often as possible, to prevent and treat no-reflow.
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Affiliation(s)
- Ao Qiang Guo
- Department of Geriatric Nephrology, Institute of Gerontology, Chinese PLA General Hospital, Beijing 100853, China
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Grygier M, Araszkiewicz A, Lesiak M, Grajek S. Effect of New Method of Intracoronary Adenosine Injection during Primary Percutaneous Coronary Intervention on Microvascular Reperfusion Injury - Clinical Outcome and 1-Year Follow-Up. Cardiology 2013; 124:199-206. [DOI: 10.1159/000346876] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 12/14/2012] [Indexed: 11/19/2022]
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Sharma V, Bell RM, Yellon DM. Targeting reperfusion injury in acute myocardial infarction: a review of reperfusion injury pharmacotherapy. Expert Opin Pharmacother 2012; 13:1153-75. [PMID: 22594845 DOI: 10.1517/14656566.2012.685163] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Acute myocardial infarction (AMI) (secondary to lethal ischemia-reperfusion [IR]) contributes to much of the mortality and morbidity from ischemic heart disease. Currently, the treatment for AMI is early reperfusion; however, this itself contributes to the final myocardial infarct size, in the form of what has been termed 'lethal reperfusion injury'. Over the last few decades, the discovery of the phenomena of ischemic preconditioning and postconditioning, as well as remote preconditioning and remote postconditioning, along with significant advances in our understanding of the cardioprotective pathways underlying these phenomena, have provided the possibility of successful mechanical and pharmacological interventions against reperfusion injury. AREAS COVERED This review summarizes the evidence from clinical trials evaluating pharmacological agents as adjuncts to standard reperfusion therapy for ST-elevation AMI. EXPERT OPINION Reperfusion injury pharmacotherapy has moved from bench to bedside, with clinical evaluation and ongoing clinical trials providing us with valuable insights into the shortcomings of current research in establishing successful treatments for reducing reperfusion injury. There is a need to address some key issues that may be leading to lack of translation of cardioprotection seen in basic models to the clinical setting. These issues are discussed in the Expert opinion section.
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Affiliation(s)
- Vikram Sharma
- The Hatter Cardiovascular Institute, 67 Chenies Mews, London WC1E 6HX, UK
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Singh M, Shah T, Khosla K, Singh P, Molnar J, Khosla S, Arora R. Safety and efficacy of intracoronary adenosine administration in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Ther Adv Cardiovasc Dis 2012; 6:101-14. [DOI: 10.1177/1753944712446670] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: Studies evaluating intracoronary administration of adenosine for prevention of microvascular dysfunction and ischemic-reperfusion injury in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) have yielded mixed results. Therefore, we performed a meta-analysis of these trials to evaluate the safety and efficacy of intracoronary adenosine administration in patients with AMI undergoing primary PCI. Methods: A total of seven prospective randomized controlled trials were analyzed. The endpoints extracted were post-procedure residual stent thrombosis (ST) segment elevation and ST segment resolutions (STRes), difference in peak creatine kinase (CK-MB) concentration, thrombolysis in myocardial infarction (TIMI) grade III flow (TIMI 3 flow), myocardial blush grade (MBG) 3, mean difference in post-PCI ejection fraction (EF), all-cause mortality, cardiovascular mortality, heart failure (HF) and major adverse cardiovascular event (MACE). Safety endpoints analyzed were bradycardia, second-degree atrioventricular block (AVB), ventricular tachycardia (VT), ventricular fibrillation (VF) and recurrence of chest pain (CP). The endpoints were analyzed by standard methods of meta-analysis. Results: Intracoronary adenosine therapy led to significantly more post-PCI STRes [relative risk (RR) 1.39, 95% confidence interval (CI) 1.01–1.90; p = 0.04] and reduction in residual ST segment elevation (RR 0.82, CI 0.69–0.99; p = 0.04) but did not improve TIMI 3 flow (RR 1.09, CI 0.94–1.27; p = 0.25), MBG3 (RR 1.04, CI 0.65–1.69; p = 0.88), peak CK-MB concentration (mean difference −39.43, CI −120.223 to 41.371; p = 0.339) and post-PCI EF (mean difference 1.238, CI −5.802 to 8.277; p = 0.730). There was a trend towards improvement and MACE (RR 0.64, CI 0.40–1.03; p = 0.06), incidence of HF (RR 0.47, CI 0.19–1.12; p = 0.08) and CV mortality (RR 0.15, CI 0.02–1.23; p = 0.08) that did not reach statistical significance but no difference in all-cause mortality (RR 0.77, CI 0.25–2.34; p = 0.64). Safety analysis showed no significant difference in CP events (RR 1.26, CI 0.55–2.86; p = 0.58), bradycardia (RR 2.19, CI 0.24–0.38; p = 0.49), VT (odds ratio 0.61, CI 0.08–4.90; p = 0.64) and VF (RR 0.49, CI 0.13–1.90; p = 0.30), but significantly more second-degree AVB (RR 7.88, CI 4.15–14.9; p < 0.01) in the adenosine group compared with the placebo group. Conclusion: Intracoronary adenosine administration was well tolerated and significantly improved electrocardiographic outcomes with a tendency towards improvement in MACE, HF and CV mortality that could not reach statistical significance.
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Affiliation(s)
- Mukesh Singh
- Department of Cardiology, Chicago Medical School, 3333, Green Bay Road, North Chicago, IL 60068, USA
| | - Tejaskumar Shah
- Department of Cardiology, Chicago Medical School, North Chicago, IL, USA
| | - Kavia Khosla
- Department of Cardiology, Chicago Medical School, North Chicago, IL, USA
| | - Param Singh
- Department of Cardiology, Chicago Medical School, North Chicago, IL, USA
| | - Janos Molnar
- Department of Cardiology, Chicago Medical School, North Chicago, IL, USA
| | - Sandeep Khosla
- Department of Cardiology, Chicago Medical School, North Chicago, IL, USA
| | - Rohit Arora
- Department of Cardiology, Chicago Medical School, North Chicago, IL, USA
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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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Relationship between angiographic dynamic and densitometric assessment of myocardial reperfusion and survival in patients with acute myocardial infarction treated with primary percutaneous coronary intervention: the harmonizing outcomes with revascularization and stents in AMI (HORIZONS-AMI) trial. Am Heart J 2011; 162:1044-51. [PMID: 22137078 DOI: 10.1016/j.ahj.2011.08.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 08/30/2011] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We evaluated 2 different methods of assessing tissue myocardial perfusion (TMP) and its impact on long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND Although primary percutaneous coronary intervention restores brisk epicardial flow in approximately 90% of patients with STEMI, normal TMP is less commonly achieved. Tissue myocardial perfusion has been shown to correlate mostly with early clinical outcomes. METHODS We analyzed the outcomes of 3,267 patients in the HORIZONS-AMI study according to final TMP, assessed by angiographic dynamic (Dyn) and densitometric (Den) methods. Multivariable analysis was performed to identify the independent influence of TMP grade 2/3 on late survival. RESULTS Dyn TMP 2/3 was achieved in 2,600 patients (79.6%), whereas Den TMP 2/3 was achieved in 2,483 (76.0%). Mortality was significantly lower in those with Dyn TMP 2/3 compared with TMP 0/1 at 30 days (1.1% vs 6.9%, P < .0001) and at 3 years (5.1% vs 11.2%, P < .0001). Similar results were obtained with Den TMP. Dyn TMP 2/3 was an independent predictor of mortality at both time points (HR 0.21, 95% CI 0.12-0.37, P < .0001 and HR 0.53, 95% CI 0.38-0.73, P < .0001, respectively), as was Den TMP. Survival was comparable in patients with TMP 2 and TMP 3. CONCLUSIONS Angiographic TMP can be assessed reliably using either Dyn or Den methods and is a powerful, independent predictor of early and late mortality after primary percutaneous coronary intervention in STEMI.
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Navarese EP, Buffon A, Andreotti F, Gurbel PA, Kozinski M, Kubica A, Musumeci G, Cremonesi A, Tavazzi L, Kubica J, Castriota F. Adenosine improves post-procedural coronary flow but not clinical outcomes in patients with acute coronary syndrome: a meta-analysis of randomized trials. Atherosclerosis 2011; 222:1-7. [PMID: 22153149 DOI: 10.1016/j.atherosclerosis.2011.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 11/01/2011] [Accepted: 11/02/2011] [Indexed: 02/06/2023]
Abstract
AIMS Adjunctive therapy with adenosine has been shown to improve coronary flow in patients with acute coronary syndromes (ACS); it is unclear, however, whether adenosine can effectively reduce adverse clinical events. The aim of our study was to perform a meta-analysis of all randomized controlled trials (RCTs) investigating angiographic and clinical outcomes in ACS patients undergoing PCI or thrombolysis and receiving adjunctive adenosine therapy vs. placebo. METHODS Medline/CENTRAL/EMBASE and Google Scholar database were scanned. The meta-analysis included ten RCTs (N=3821). All-cause mortality was chosen as primary endpoint. Secondary endpoints were re-infarction (MI), heart failure (HF) symptoms (NYHA class III/IV), no-reflow (defined as TIMI 0 flow) and >50% ST-resolution. RESULTS Adenosine compared to placebo was associated with a significant reduction of post-procedural no-reflow (OR [95% CI]=0.25 [0.08-0.73], p=0.01); however, at a median follow-up of 6 months, prior treatment with adenosine did not confer significant benefits in terms of reduction of mortality (OR(Fixed) [95% CI]=0.87 [0.69-1.09], p=0.23), as well as re-MI (p=0.80), HF symptoms (p=0.44) and ST-resolution (p=0.09). Separate analyses conducted in the subgroups of ST-elevation MI patients treated with either PCI or thrombolysis confirmed the findings found in the overall population. CONCLUSIONS This meta-analysis shows that adenosine adjunctive therapy does not improve survival nor reduce the rates of re-MI and HF symptoms in patients with ACS treated with PCI or thrombolysis. The beneficial effect on post-procedural coronary flow was not associated with consistent advantages on clinical outcomes.
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Affiliation(s)
- Eliano Pio Navarese
- Interventional Cardio-Angiology Unit, GVM Care and Research, Cotignola, RA, Italy.
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