Clinical significance of no-reflow in different stages of primary angioplasty among patients with acute myocardial infarctions

Effect of coronary flow on intracoronary alteplase: a prespecified analysis from a randomised trial

OBJECTIVES

Persistently impaired culprit artery flow (

METHODS

In T-TIME (trial of low-dose adjunctive alTeplase during primary PCI), patients ≤6 hours from onset of ST-elevation myocardial infarction (STEMI) were randomised to placebo, alteplase 10 mg or alteplase 20 mg, administered by infusion into the culprit artery, pre-stenting. In this prespecified, secondary analysis, coronary flow was assessed angiographically at the point immediately before drug administration. Microvascular obstruction, myocardial haemorrhage and infarct size were assessed by cardiovascular magnetic resonance (CMR) at 2-7 days and 3 months.

RESULTS

TIMI flow was assessed after first treatment (balloon angioplasty/aspiration thrombectomy), immediately pre-drug administration, in 421 participants (mean age 61±10 years, 85% male) and was 3, 2 or 1 in 267, 134 and 19 participants respectively. In patients with TIMI flow ≤2 pre-drug, there was higher incidence of microvascular obstruction with alteplase (alteplase 20 mg (53.1%) and 10 mg (59.5%) combined versus placebo (34.1%); OR=2.47 (95% CI 1.16 to 5.22, p=0.018) interaction p=0.005) and higher incidence of myocardial haemorrhage (alteplase 20 mg (53.1%) and 10 mg (57.9%) combined vs placebo (27.5%); OR=3.26 (95% CI 1.44 to 7.36, p=0.004) interaction p=0.001). These effects were not observed in participants with TIMI 3 flow pre-drug. There were no interactions between TIMI flow pre-drug, alteplase and 3-month CMR findings.

CONCLUSION

In patients with impaired culprit artery flow (

TRIAL REGISTRATION NUMBER

NCT02257294.

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Key Words

• acute myocardial infarction

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MESH Headings Collapse

Grants

• FS/16/74/32573 British Heart Foundation
• MC_PC_12037 Medical Research Council
• MC_PC_15113 Medical Research Council

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Affiliation(s)

Annette Marie Maznyczka Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
Peter McCartney Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
Patrycja Duklas Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
Margaret McEntegart Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
Keith G Oldroyd Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
John P Greenwood Department of Cardiology, Leeds General Infirmary, Leeds, UK Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
Douglas Muir James Cook University Hospital, Middlesbrough, UK
Saqib Chowdhary Manchester University NHS Foundation Trust, Manchester, UK
Anthony H Gershlick Division of Cardiology, University of Leicester, Leicester, UK
Clare Appleby Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
Hany Eteiba Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
James Cotton Department of Cardiology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
Andrew Wragg Barts and The London Hospital, London, UK
Nick Curzen Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
R Campbell Tait Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
Peter MacFarlane Electrocardiology Group, Royal Infirmary, Glasgow, UK
Paul Welsh British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
Naveed Sattar British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
Mark C Petrie British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
Ian Ford Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
Keith A A Fox Department of Cardiology, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
Alex McConnachie Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
Colin Berry Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK

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No-reflow phenomenon and comparison to the normal-flow population postprimary percutaneous coronary intervention for ST elevation myocardial infarction: case-control study (NORM PPCI)

Introduction

No-reflow (NR) phenomenon is characterised by the failure of myocardial reperfusion despite the absence of mechanical coronary obstruction. NR negatively affects patient outcomes, emphasising the importance of prediction and management. The objective was to evaluate the incidence and independent predictors of NR in patients presenting with ST-elevation myocardial infarction (STEMI).

Methods

This was a single-centre prospective case–control study. Cases were subjects who suffered NR, and the control comparators were those who did not. Clinical outcomes were documented. Salient variables relating to the patients and their presentation, history and angiographical findings were compared using one-way analysis of variance or χ² test. Multiple regression determined the independent predictors, and a risk score was established based on the β coefficient.

Results

Of 173 consecutive patients, 24 (13.9%) suffered from NR, with 46% occurring post stent implantation. Patients with NR had increased risk of in-hospital death (OR 7.0, 95% CI 1.3 to 36.7, p=0.022). From baseline variables available prior to percutaneous coronary intervention, the independent predictors of NR were increased lesion complexity, admission systolic hypertension, weight of <78 kg and history of hypertension. Continuous data were transformed into best-fit binary variables, and a risk score was defined. Significant difference was demonstrated between the risk score of patients with NR (4.1±1) compared with controls (2.6±1) (p<0.001), and the risk score was considered a good test (area under the curve=0.823). A score of ≥4 had 75% sensitivity and 76.5% specificity.

Conclusion

Patients with NR have a higher rate of mortality following STEMI. Predictors of NR include lesion complexity, systolic hypertension and low weight. Further validation of this risk model is required.