Association of endothelial dysfunction and no-reflow during primary percutaneous coronary intervention for ST-elevation myocardial infarction

Correlation between endothelial dysfunction and occurrence of no-reflow in patients undergoing post-thrombolysis early invasive percutaneous intervention for ST-elevation myocardial infarction

Background

Endothelial dysfunction and no-reflow share microcirculatory obstruction as a common pathophysiological mechanism. This study evaluated the relationship between systemic peripheral endothelial dysfunction assessed by flow-mediated dilatation (FMD) of the brachial artery and no-reflow in patients with ST-segment elevation myocardial infarction (STEMI) who received successful fibrinolysis.

Results

This study included 150 patients managed by the percutaneous coronary intervention (PCI) after successful fibrinolysis. Patients were divided according to coronary angiographic success into normal flow versus no-reflow groups. According to FMD measured through brachial artery ultrasound, patients were divided based on their endothelial function into endothelial dysfunction versus normal endothelial function. No-reflow occurred in 44 patients (29.3%). No-reflow patients had longer pain to door time (6.52 ± 1.82 vs 5.19 ± 1.85 h), more Killip class II (36.4% vs 16%, p = 0.006), and lower FMD (7.26 ± 1.92 vs 8.23 ± 2.76%, p = 0.036). Also, they showed more endothelial dysfunction; however, this difference was statistically nonsignificant (97.7% vs 87.7%, p = 0.055). One hundred and thirty-six patients (90.7%) had endothelial dysfunction. They were older (57.51 ± 5.92 vs 50.86 ± 4.55 years, p value ≤ 0.001), more smokers (41.2% vs 14.3%, p = 0.04). Patients with normal endothelial function had a more myocardial blush grade (MBG) 3 (78.6% vs 26.5%, p value = 0.001) in comparison with more MBG 2 in those with endothelial dysfunction (41.9% vs 14.3%, p value = 0.001). Endothelial dysfunction patients had nonsignificant more no-reflow (31.6% vs 7.1%, p-value: 0.06). There was a significant weak positive correlation between thrombolysis in myocardial infarction (TIMI) flow and FMD (r = 0.174, p = 0.033) and a significant moderate positive correlation between MBG and FMD (r = 0.366, p < 0.001). Patients with TIMI I flow had significantly lower FMD compared with patients with TIMI II and TIMI III flow post-PCI. FMD ≤ 6% could predict post-procedural TIMI I flow.

Conclusions

In STEMI patients who underwent PCI within 24 h after successful fibrinolysis, those who had no-reflow showed worse peripheral systemic endothelial function as they had lower brachial artery FMD. Also, FMD showed a significant positive correlation with the post-procedural angiographic flow (TIMI flow and MBG). FMD ≤ 6% could predict TIMI I flow.

Endothelial Dysfunction and Its Clinical Implications

Endothelial dysfunction (ED) plays a substantial role in the pathogenesis of atherosclerosis and some other vascular diseases. ED has been demonstrated in patients with hypercholesterolemia, diabetes, smoking, hypertension, and in patients with atherosclerotic disease. Besides classical risk factors, ED is affected by chronic inflammatory diseases and acute infections, particularly viral diseases. Causes of ED include oxidative stress, inflammation, and shear stress, which decrease the bioavailability of nitric oxide. Markers of ED have been sought, particularly circulating markers. Using these tests, it is possible to evaluate the response to harmful effects of risk factors and the effects of treatment on vessel wall function. Endothelial dysfunction is significantly and directly correlated with the occurrence of cardiac events and the risk of cardiac events increase as ED worsens. Because endothelial function plays a central role in atherogenesis it became a therapeutic target. Endothelial dysfunction is reversible and its improvement may be achieved by elimination of risk factors, inhibitors of endothelium-derived contracting factors (angiotensin-converting enzyme), smoking cessation, lipid-lowering drugs, diet, and physical exercise. By reversing ED, it is possible to restore vascular function.

No-Reflow after PPCI-A Predictor of Short-Term Outcomes in STEMI Patients

The no-reflow phenomenon following primary percutaneous coronary intervention (PPCI) in acute ST-elevation myocardial infarction (STEMI) patients is a predictor of unfavorable prognosis. Patients with no-reflow have many complications during admission, and it is considered a marker of short-term mortality. The current research emphasizes the circumstances of the incidence and complications of the no-reflow phenomenon in STEMI patients, including in-hospital mortality. In this case-control study, conducted over two and a half years, there were enrolled 656 patients diagnosed with STEMI and reperfused through PPCI. Several patients (n = 96) developed an interventional type of no-reflow phenomenon. One third of the patients with a no-reflow phenomenon suffered complications during admission, and 14 succumbed. Regarding complications, the majority consisted of arrhythmias (21.68%) and cardiogenic shock (16.67%). The anterior localization of STEMI and the left anterior descending artery (LAD) as a culprit lesion were associated with the highest number of complications during hospitalization. At the same time, the time interval >12 h from the onset of the typical symptoms of myocardial infarction (MI) until revascularization, as well as multiple stents implantations during PPCI, correlated with an increased incidence of short-term complications. The no-reflow phenomenon in patients with STEMI was associated with an unfavorable short-term prognosis.

Nesfatin-1 Levels Predict Angiographic No-Reflow in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND

Nesfatin-1 is a novel peptide possessing pleiotropic metabolic effects. No-reflow phenomenon (NR) is a poor prognostic indicator occurring in around 30% of all patients undergoing primary percutaneous coronary interventions (pPCI). Inflammation and complexity of coronary artery disease (CAD) play pivotal roles in the pathogenesis of NR. In this study, we investigated the relationship between admission serum nesfatin-1 level, NR and complexity of CAD assessed by SYNTAX-1 (SS-1) and SYNTAX-2 (SS-2) scores in patients with ST-segment elevation myocardial infarction (STEMI) undergoing pPCI.

METHODS

A total of 174 STEMI patients who underwent pPCI were included in the study and divided into NR (n = 36) and normal flow (n = 138) groups. Serum nesfatin-1 was measured by enzyme-linked immunosorbent assay. Seventy-eight consecutive age-, gender- and co-morbidity-matched patients undergoing coronary angiography with < 50% stenosis comprised the control group.

RESULTS

Nesfatin-1 levels were significantly lower in the NR group compared to the normal flow and control groups (10.8 ± 6.6 ng/mL vs. 34.9 ± 24 ng/mL vs. 43.6 ± 23.2 ng/mL, respectively, p < 0.001). Nesfatin-1 was significantly and inversely correlated with SS-1 and SS-2 scores (r = -0.709 and r = -0.655, respectively, both p < 0.001). Multivariate logistic regression analysis showed that nesfatin-1 [odds ratio (OR) = 0.81, 95% confidence interval (CI) = 0.708-0.936, p = 0.004] and glomerular filtration rate (OR = 0.94, 95% CI = 0.892-0.989, p = 0.018) were independently associated with NR. In the receiver operating characteristic analysis, nesfatin-1 < 15.21 ng/mL predicted NR with 78.4% sensitivity and 72.2% specificity (area under the curve = 0.809, 95% CI = 0.701-0.918, p < 0.001).

CONCLUSIONS

Admission nesfatin-1 level is a potent predictor of NR in STEMI patients undergoing pPCI. Additionally, nesfatin-1 has a robust and negative correlation with the complexity of CAD.

Effects of Xin-Ji-Er-Kang on heart failure induced by myocardial infarction: Role of inflammation, oxidative stress and endothelial dysfunction

BACKGROUND

Xin-Ji-Er-Kang (XJEK) is a Chinese herbal formula, which has been reported to exert effective protection on cardiovascular diseases like hypertension and myocarditis.

PURPOSE

To elucidate the protective effects of XJEK on heart failure (HF) induced by myocardial infarction (MI) through the amelioration of inflammation, oxidative stress (OS) and endothelial dysfunction(ED).

MATERIALS AND METHODS

Fifty-seven male KM mice were randomized into the following six groups (n = 9-10 for each): control group, model group, MI+XJEK low dose group(XJEKL) group, MI+XJEK middle dose group(XJEKM), MI+XJEK high dose group(XJEKH), and MI+fosinopril group (positive control group). After treatment for four weeks, electrocardiography (ECG) and haemodynamics were recorded. Serum and tissues were collected for further analysis. Endothelium-dependent relaxation induced by acetylcholine was assessed in isolated thoracic aorta ring experiment. Hematoxylin and eosin (HE) and Van Gieson (VG) staining were used to detect the pathological changes of heart and thoracic aorta. Colorimetric analysis was employed to determine serum nitric oxide level (NO), malondialdehyde (MDA) concentration and superoxide dismutase (SOD) activity. ELISA was used to detect serum B-type natriuretic peptide (BNP) and serum inflammatory cytokines, as well as endothelial NO synthetase (eNOS), angiotensinII (Ang II) and endothelin-1(ET-1) concentration in both serum and cardiac tissues. Immunohistochemistry and Western blotting (WB) were employed to detect eNOS and inflammatory cytokine expressions in cardiac tissues.

RESULTS

XJEK administration markedly ameliorated cardiac dysfunction and abnormal ECG manifested by decreased weight/body weight (HW/BW) ratio, BNP and remedied hypertrophy of cardiomyocytes and deposition of collagen, which might be in part attributed to the increased SOD and decreased MDA in serum. Furthermore, XJEK administration improved ED with boosted eNOS activities in serum and cardiac tissues, as well as up-regulated NO levels in serum, down-regulated Ang II and ET-1 content in serum and cardiac tissues. Lastly, protein expression of pro-inflammation cytokines significantly decreased, and anti-inflammatory cytokine was significantly enhanced in serum and cardiac tissues compared to model group.

CONCLUSION

XJEK may exert beneficial effects on HF induced by MI in mice, and the underlying mechanism may be attributable to the amelioration of ED, anti-OS and anti-inflammation effects.