Cardiovascular events associated with nicorandil administration prior to primary percutaneous coronary intervention in patients with acute ST-segment elevated myocardial infarction: a systematic review and meta-analysis

Mechanism of Coronary Microcirculation Obstruction after Acute Myocardial Infarction and Cardioprotective Strategies

ST-segment elevation myocardial infarction patients are best treated with emergency percutaneous coronary intervention (PCI), while coronary microvascular dysfunction and obstruction (CMVO) are indicated by the absence or slowing of antegrade epicardial flow on angiography, resulting in suboptimal myocardial perfusion despite the lack of mechanical vascular obstruction. CMVO occurs in up to half of patients who undergo PCI for the first time and is associated with poor outcomes. This review summarizes the complex mechanisms leading to CMVO and elaborates on the changes observed at the organism, tissue, organ, cellular, and molecular levels. It also describes the current diagnostic methods and comprehensive treatment methods for CMVO.

Effects of Nicorandil Administration on Infarct Size in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: The CHANGE Trial

Background Nicorandil was reported to improve microvascular dysfunction and reduce reperfusion injury when administered before primary percutaneous coronary intervention. In this multicenter, prospective, randomized, double-blind clinical trial (CHANGE [Effects of Nicorandil Administration on Infarct Size in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention]), we investigated the effects of nicorandil administration on infarct size in patients with ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention. Methods and Results A total of 238 patients with ST-segment-elevation myocardial infarction were randomized to receive intravenous nicorandil (n=120) or placebo (n=118) before reperfusion. Patients in the nicorandil group received a 6-mg intravenous bolus of nicorandil followed by continuous infusion at a rate of 6 mg/h. Patients in the placebo group received the same dose of placebo. The predefined primary end point was infarct size on cardiac magnetic resonance (CMR) imaging performed at 5 to 7 days and 6 months after reperfusion. CMR imaging was performed in 201 patients (84%). Infarct size on CMR imaging at 5 to 7 days after reperfusion was significantly smaller in the nicorandil group compared with the placebo (control) group (26.5±17.1 g versus 32.4±19.3 g; P=0.022), and the effect remained significant on long-term CMR imaging at 6 months after reperfusion (19.5±14.4 g versus 25.7±15.4 g; P=0.008). The incidence of no-reflow/slow-flow phenomenon during primary percutaneous coronary intervention was much lower in the nicorandil group (9.2% [11/120] versus 26.3% [31/118]; P=0.001), and thus, complete ST-segment resolution was more frequently observed in the nicorandil group (90.8% [109/120] versus 78.0% [92/118]; P=0.006). Left ventricular ejection fraction on CMR imaging was significantly higher in the nicorandil group than in the placebo group at both 5 to 7 days (47.0±10.2% versus 43.3±10.0%; P=0.011) and 6 months (50.1±9.7% versus 46.4±8.5%; P=0.009) after reperfusion. Conclusions In the present trial, administration of nicorandil before primary percutaneous coronary intervention led to improved myocardial perfusion grade, increased left ventricular ejection fraction, and reduced myocardial infarct size in patients with ST-segment-elevation myocardial infarction. Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03445728.

Effects of nicorandil on systemic inflammation and oxidative stress induced by percutaneous coronary intervention in patients with coronary heart disease

Objective

The present study investigated the effects of a bolus intracoronary injection of nicorandil on systemic inflammation and oxidative stress induced by percutaneous coronary intervention (PCI) in patients with coronary heart disease (CHD).

Methods

Patients undergoing coronary angiography (CAG) were enrolled into the CAG group (n = 30). Patients undergoing PCI were randomly divided into the PCI (n = 30) and PCI + nicorandil groups (n = 30).

Results

Blood taken from patients in the placebo group 24 hours after PCI exhibited significant increases in the expression of inflammatory indicators and mild increases in the expression of anti-inflammatory indicators. The intracoronary injection of nicorandil reversed the elevation of inflammatory indicators and significantly increased the levels of anti-inflammatory indicators in the blood of patients with PCI. Blood taken from patients in the placebo group 24 hours after PCI also displayed significant decreased superoxide dismutase levels and increased malondialdehyde levels. Nicorandil treatment reversed these changes of oxidative stress marker levels.

Conclusions

These results indicated the possible medical application of intracoronary injections of nicorandil for reducing systemic inflammation and oxidative stress in the peripheral blood of patients undergoing PCI.

Effect of nicorandil treatment adjunctive to percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis

Objective

There is controversy whether nicorandil treatment has cardioprotective effects in patients with acute myocardial infarction (AMI) following percutaneous coronary intervention (PCI). This meta-analysis was conducted to assess the efficacy of nicorandil on functional and clinical outcomes after PCI.

Methods

Systematic databases were searched to retrieve studies that compared the effect of nicorandil with a control group in patients with AMI who underwent PCI. Outcomes related to coronary blood flow, and functional and clinical outcomes were extracted and a meta-analysis was performed. Trial sequential analysis was conducted to estimate the required sample size for statistical power.

Results

Twenty-four trials involving 2965 patients with AMI were enrolled. Pooled results showed that nicorandil treatment significantly suppressed the incidence of no-reflow phenomenon and reperfusion arrhythmia after reperfusion, improved the left ventricular ejection fraction and left ventricular end-systolic volume index, and reduced major adverse cardiovascular events and cardiovascular death. Trial sequential analysis confirmed the effect of nicorandil in reducing the incidence of no-reflow phenomenon and follow-up major adverse cardiovascular events in patients with AMI after PCI.

Conclusion

Our findings suggest that nicorandil treatment adjunctive to reperfusion therapy improves myocardial reperfusion, cardiac function, and clinical outcomes in patients with AMI.

Cardioprotective role of phyllanthin against myocardial ischemia-reperfusion injury by alleviating oxidative stress and inflammation with increased adenosine triphosphate levels in the mice model

BACKGROUND

Ischemic heart disease is an imperative cause of high morbidity and mortality globally. The cardiac ischemia/reperfusion damage occur in both reperfusion and ischemia.

OBJECTIVE

In this exploration, we have planned to examine the cardio-protective action of phyllanthin against the myocardial ischemic-reperfusion injury in mice.

MATERIALS AND METHODS

The myocardial ischemic reperfusion injury (MI-RI) stimulated via coronary artery occlusion, followed by the 10 mg/kg of phyllanthin treatment. The serum cardiac markers and pro-inflammatory markers level was investigated by using the assay kits. The expressions of oxidative stress and inflammatory markers level were investigated by immunohistochemical analysis. Lipid peroxidation, antioxidant enzymes, and ATPase levels level was examined by standard methods. The expression of oxidative stress markers were inspected by the reverse transcription polymerase chain reaction technique. The heart histology was investigated microscopically.

RESULTS

The phyllanthin treatment increased the body weight, and heart weight also diminished the infarct size in the MI/RI mice. Cardiac markers status was diminished and the blood pressure markers were augmented by the phyllanthin. Histological analysis revealed the protective role of phyllanthin. Suppressed lipid peroxidation and enhanced antioxidant enzymes were noted in the phyllanthin treated mice MI-RI mice. Phyllanthin appreciably suppressed the pro-inflammatory regulators that is, NF-αB p65, IL-6, IL-1β, and TNF-α and enhanced the antioxidant marker expressions. ATPase levels were improved by the phyllanthin in the MI-RI mice.

CONCLUSION

These novel findings were confirmed the therapeutic role of phyllanthin against the MI-RI in mice. Hence, it can be a promising agent to treat the MI-RI induced cardiac dysfunction.

The Efficacy and Safety of Nicorandil for Periprocedural Myocardial Injury in Patients Undergoing PCI: A Meta-Analysis

Purpose

To evaluate the efficacy and safety of nicorandil for periprocedural myocardial injury in patients undergoing PCI through meta-analysis of randomized controlled trials.

Methods

We analyzed the clinical data of patients including the incidence of periprocedural myocardial injury (PMI) and major adverse cardiovascular events (MACE) from selected articles. RCTs were retrieved from medical literature databases. RR and 95% confidence intervals (CI) were calculated to compare the endpoints.

Results

In total, 15 articles (16 trial comparisons) were retrieved which contained 2221 patients. In general, 1130 patients (50.9%) were randomized to the experimental group, whereas 1091 patients (49.1%) were randomized to the control group. The result showed that nicorandil significantly reduced the incidence of PMI and MACE after PCI compared to the control group.

Conclusions

Overall, early use of nicorandil in patients undergoing percutaneous coronary intervention (PCI) was associated with a significant reduction of PMI and MACE.

Nicorandil for Periprocedural Myocardial Injury in Elective Percutaneous Coronary Intervention: A Meta-Analysis of 10 Randomized Controlled Trials

The clinical outcomes of nicorandil in percutaneous coronary intervention (PCI) are conflicting. We sought to evaluate the effects of nicorandil on periprocedural myocardial injury (PMI) in elective PCI. Eligible studies that reported the effect of nicorandil on PMI in elective PCI were obtained from PubMed, Web of Science, and Cochrane Library (up to October 28, 2019). The outcomes were PMI and major adverse cardiovascular and cerebrovascular events (MACCEs). Ten randomized controlled trials with 1304 patients undergoing elective PCI were evaluated. Nicorandil significantly reduced the incidence of PMI (odds ratio [OR] = 0.48; P = .0003); however, there was no significant difference in MACCEs (OR = 0.80; P = .45) between the 2 groups. Subgroup analyses showed that nicorandil significantly lowered the PMI risk when only patients with stable coronary artery disease (OR = 0.41; P = .0008) were considered and when nicorandil was administered intravenously (OR = 0.41; P = .0007) or orally (OR = 0.33; P = .0001). This meta-analysis suggests that nicorandil could reduce the incidence of PMI without increasing the occurrence of MACCEs in elective PCI. The effect of nicorandil in lowering the PMI risk is associated with the diagnosis of the patients and the route of nicorandil administration.

Ginsenoside Rb1 attenuates cardiomyocyte apoptosis induced by myocardial ischemia reperfusion injury through mTOR signal pathway

OBJECTIVE

Ginsenoside Rb1 (GRb1) is known to play an effective protection on myocardial infarction, yet its therapeutic mechanism on myocardial ischemia/reperfusion (I/R) injury has remained obscure. Here we sought to investigate the protective mechanism of GRb1 preconditioning on myocardial I/R injury in rats.

METHODS AND RESULTS

We report here that GRb1 preconditioning could improve myocardial I/R injury induced-cardiac functions including LVDP, -dp/dt min and + dp/dt max; however, the heart rate (HR) was maintained at a level comparable to the I/R group. Additionally, in I/R injury group given GRb1 preconditioning, release of myocardial enzymes (CK-MB and Trop l) and CtsB was decreased. Moreover, GRb1 decreased the expression of apoptotic related proteins e.g. cleaved-caspase 3; however, the ratio of Bcl-2/Bax related to anti-apoptosis was decreased. The study was extended by injecting rapamycin intraperitoneally before GRb1 pretreatment. Thus, mTOR pathway was significantly upregulated after GRb1 pretreatment when compared with I/R. Remarkably, the anti-apoptosis protection of GRb1 pretreatment was attenuated by rapamycin. Furthermore, GRb1 effectively reduced the infarct size thus supporting its role in anti-myocardial I/R injury.

CONCLUSIONS

It is concluded that GRb1 preconditioning can ameliorate myocardial I/R injury as manifested by the improvement of cardiac function indices; moreover, release of myocardial enzymes, namely, CK-MB, Trop l and CtsB was reduced. More importantly, we have shown that the protective effect of GRb1 against I/R injury induced cardiomyocyte apoptosis is associated with the activation of mTOR signal pathway as evident by the use of rapamycin.