no-reflow

Percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for acute coronary syndrome. However, no-reflow can still occur and is associated with worse in-hospital and long-term prognoses. This study aims to assess the impact of high-dose atorvastatin loading before primary PCI on ST-elevation myocardial infarction (STEMI) patients with no-reflow and major adverse cardiovascular events (MACE) after 1 month.

Two hundred STEMI patients undergoing primary PCI were allocated and randomized into 2 groups: the study group received high-intensity statin (80 mg of atorvastatin) in addition to guideline-recommended therapy before primary PCI, while the control group received guideline-recommended therapy before primary PCI. Angiographic and echocardiographic assessments were thoroughly conducted for both groups.

No significant differences in demographic data were observed between the 2 groups. A significant decrease in the no-reflow phenomenon was seen in the study group compared with the control group (28% vs 47%; P = 0.006). Moreover, a better myocardial blush grade was noted in the study group (0–1: 28% vs 43% and 2–3: 72% vs 57%; P = 0.027), along with a higher ejection fraction 24 hours after PCI (mean ± SD = 48.35 ± 8.78 vs 45.20 ± 7.89; P = 0.008) and improved ejection fraction after 1 month (43% vs 20%; P = 0.039). Nonetheless, no significant impact on MACE was found after 1 month.

High-dose atorvastatin loading before primary PCI led to improvements in postprocedural myocardial blush grade, the no-reflow phenomenon, and ejection fraction (both after 24 hours and 1 month). Still, no significant reduction in MACE was observed after 1 month. Despite this, our findings support the routine use of high-dose atorvastatin before primary PCI in patients presenting with STEMI. 

Recent guidelines recommend the use of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score for bleeding risk stratification and determining the appropriate duration of DAPT following primary percutaneous coronary intervention (PPCI). Our study aimed to assess the predictive value of the PRECISE-DAPT score for not only bleeding complications but also in-hospital and short-term complications, including major adverse cardiovascular events (MACEs) and no-reflow.
 

The study included 241 patients diagnosed with STEMI and eligible for PPCI. The patients were divided into 3 groups according to their PRECISE-DAPT score value: low (<17), intermediate (17–24), and high (≥25) score groups. Finally, in-hospital and short-term (180 d) follow-ups for MACEs, no-reflow, and bleeding complications were done.
 

In-hospital and short-term complications were higher among the high-score group than in the other groups (P<0.001). The high-score group had lower thrombosis in myocardial infarction (TIMI flow<III) than the other groups, which was statistically significant (P= 0.001). The PRECISE-DAPT score had good predictive power for in-hospital complications (AUC=0.64) and short-term follow-up MACEs (AUC=0.80; P=0.004 and P<0.001, respectively), demonstrating good sensitivity and specificity of the PRECISE-DAPT score for the prediction of in-hospital complications, no-reflow, bleeding complications, and follow-up MACEs.
 

The PRECISE-DAPT score had a strong and independent predictive value for in-hospital, short-term MACEs, no-reflow, and bleeding complications among STEMI patients treated with PPCI.

Even when epicardial blood flow is restored, achieving adequate perfusion to the microvascular level is the goal. The generous utilization of antithrombotics may facilitate bleeding. We aimed to compare the efficacy in preventing no-reflow between ticagrelor and traditional loading with clopidogrel in diabetic patients presenting with ST-segment-elevation myocardial infarction (STEMI) and to assess the safety of ticagrelor administration regarding the short-term bleeding risk.
 
The present single-center prospective randomized trial consecutively randomized 300 diabetic patients admitted to the emergency department with STEMI into 2 groups: ticagrelor and clopidogrel. All the patients underwent primary percutaneous coronary intervention (PCI), during which the thrombolysis in myocardial infarction (TIMI) flow grade and the myocardial blush grade (MBG) were recorded. We followed up on the patients for 3 months to detect short-term major adverse cardiovascular events (MACE) and bleeding events.
 
The mean age of the studied population was 56 years, with a male predominance (70%). The median pain-to-door time was 8 hours. The no-reflow phenomenon was encountered more frequently in the clopidogrel group than in the ticagrelor group (37.3% vs 14%). Higher TIMI flow grades and MBGs were achieved in the ticagrelor group, and the difference was statistically significant. No significant differences, however, existed between the groups concerning MACE, stent thrombosis, and mortality. More bleeding episodes were recorded in the ticagrelor group but with no statistical significance.
 
Ticagrelor should be the first choice among P2Y12 inhibitors in the setting of primary PCI, especially in diabetic patients, due to its high efficacy and safety profile, even in elderly patients. (Iranian Heart Journal 2023; 24(4): 14-25)

The focus of this research was to explore the link between CRP (C-reactive protein) /albumin ratio (CAR), a novel inflammatory response marker, and no-reflow (NR) phenomena in non-ST elevation myocardial infarction (non-STEMI) patients during percutaneous coronary intervention (PCI).

The current study recruited 209 non-STEMI participants who underwent PCI. The patients were divided into two groups based on their post-intervention Thrombolysis in Myocardial Infarction (TIMI) flow grade; those with and without NR.

In all, 30 non-STEMI patients (6.9%) had NR after PCI. CAR values were substantially greater in the NR group. The CAR was identified to be a determinant of the NR (OR: 1.250, 95% CI: 1.033-1.513, P=0.02), although CRP and albumin were not independently related with NR in the multivariate analysis. In our investigation, low density lipoprotein-cholesterol levels and high thrombus burden were also predictors of the occurrence of NR. According to receiver operating characteristic curve evaluation, the optimal value of CAR was>1.4 with 60% sensitivity and 47% specificity in detecting NR in non-STEMI patients following PCI.

To the best of knowledge, this is the first investigation to demonstrate that the CAR, a new and useful inflammatory marker, can be utilized as a predictor of NR in patients with non-STEMI prior to PCI.

Slow flow/no reflow (SF/NR) phenomenon during emergency percutaneous revascularization is a feared complication associated with increased risk of adverse outcomes. CHA2 DS2 -VASc score has been proposed for the risk stratification but a very limited evidences are available regarding the accuracy of this system. Therefore, we conducted this study to assess the predictive value of CHA2 DS2 -VASc score for predicting SF/NR phenomenon during primary percutaneous coronary intervention (PCI).

This analytical cross-sectional study included 596 consecutive patients undergoing PCI for STEMI at a tertiary care cardiac center of Karachi, Pakistan. Baseline -VASc sore was calculated and development of SF/NR phenomenon during primary PCI was recorded. Predictive value of the score was assessed through area under the curve (AUC) of receiver operating characteristic curve analysis and sensitivity and specificity were computed. Logistic regression analysis was performed to assess the predictive strength of the score.

A total of 596 patients were included, mean age was 56.28±11.44 years, and 75.7%(451) were male. The slow/no reflow phenomenon during the procedure was observed in 36.6%(218) of the patients. CHA2 DS2 -VASc≥2 was observed in 50.2%(299) of the patients. The CHA2 DS2 -VASc score was significantly higher in SF/NR patients, 2.06±1.25 vs. 1.37±1.33; P<0.001. The AUC of CHA2 DS2 -VASc score was 0.652 [0.607-0.696], CHA2 DS2 -VASc≥2 had sensitivity and specificity of 65.6% [58.9% to 71.9%] and 58.3% [53.6% to 63.7%] respectively for predicting SF/NR. CHA2 DS2 -VASc≥2 was insignificant on multivariate with odds ratio of 1.48 [0.72 -3.04]; P=0.283.

CHA2 DS2 -VASc risk stratification system has moderate discriminating power for the stratification of SF/NR phenomenon during primary PCI.

As a promising revascularization therapy, percutaneous coronary intervention (PCI) is widely used in patients with coronary artery disease. No-reflow and low thrombolysis in myocardial infarction (TIMI) flow are two adverse periprocedural events.

This study aimed to compare the effectiveness of atorvastatin and rosuvastatin in reducing the no-reflow phenomenon in patients undergoing primary PCI.

Following a randomized control design, 280 eligible patients with no history of MI or ischemic heart disease (IHD) with ST-elevation myocardial infarction (STEMI) who were candidates for coronary angioplasty underwent angioplasty from May 2020 to December 2020.

Our results showed that TIMI flow III was significantly higher in the rosuvastatin group, while the no-reflow was not seen in this group (P < 0.001). Also, ST resolution after 90 minutes of PCI was significantly better in the rosuvastatin group.

This study demonstrated that using a loading dose of rosuvastatin could reduce the no-reflow phenomenon in patients undergoing primary PCI.

The relationship between metabolic syndrome (MS) and the MS score and the angiographic outcome of primary percutaneous coronary intervention (PPCI) for ST-segment-elevation myocardial infarction (STEMI) is still unclear. We aimed to examine the association between angiographic outcomes including angiographic no-reflow and MS.

We prospectively included 100 patients with STEMI treated with PPCI. Angiographic no-reflow was defined as a thrombolysis in myocardial infarction (TIMI) risk score of below 3 or a TIMI risk score of 3 with a myocardial blushing grade (MBG) of 0 to 1 in the absence of mechanical complications. MS was defined based on the National Cholesterol Education Program criteria. The MS score was defined as the number of MS components present.

Totally, 26 patients (26%) developed no-reflow. The patients with no-reflow had a higher prevalence of MS, a higher level of triglycerides, a lower level of high-density lipoprotein, and a higher fasting blood glucose level. The fasting blood glucose level and the time from symptom onset to wire crossing were independent predictors of the no-reflow phenomenon (OR, 1.225; 95% CI, 1.105 to 2.854; P<0.001) and (OR, 1.049; 95% CI, 1.026 to 1.073; P<0.001).
There were significant negative correlations between the MS score and both the post-intervention TIMI flow grade and MBG (P<0.001 for both).

MS plays an important role in the development of no-reflow in STEMI patients treated with PPCI with significant negative correlations between the MS score and both the post-intervention TIMI flow grade and MBG. (Iranian Heart Journal 2021; 22(4): 80-89)

The acute coronary events are one of the most common problems which are accounted to higher mortality and morbidity rate around the world. The underlying mechanism is related to occlusion, and the best therapy is to reopen the affected vessels. Many factors can influence the outcomes of percutaneous coronary intervention (PCI).

This cross-sectional study was conducted on 845 cases with acute myocardial infarction (AMI) undergoing PCI for evaluation of the "No-Reflow" phenomenon who were referred to Shahid Madani hospital in 2018. All demographic, laboratory and angiographic studies were evaluated. The obtained data were recorded and analyzed by SPSS 21.

Among 845 patients with STEMI, the incidence of angiographic no-reflow was 28% (n = 245). The older cases with co-morbid diseases and cardiac-related risk factors were considered as vulnerable to no-reflow after PCI. The other parameters were partially decisive factors for the prediction of no-reflow and mortality rate, such as higher MPV and MPV to lymphocyte ratio.

The coronary artery involvement is a troublesome event because of the established heart risk factors, and sometimes treating it with PCI could be complicated due to no-reflow. The simple predictors (i.e., MPV to lymphocyte ratio) could help us reduce morbidity and mortality.

No-reflow increases the complications and mortality rate of primary percutaneous coronary intervention (PCI). Therefore, it is important to identify patients at a higher risk of developing no-reflow. This study aimed to systematically review the prognostic value of the platelet-to-lymphocyte ratio (PLR) to predict no-reflow. The databases, such as Pubmed, EMBASE, and Web of Knowledge were searched for the relevant studies. Two authors independently performed data extraction and quality assessment of the included studies. In this meta-analysis, sensitivity and specificity of PLR, as well as the pooled odds ratio were calculated to predict no-reflow and compared with the pooled means of PLR in no-reflow and reflow groups. According to the results obtained from six out of eight studies in this systematic review, there was a significant association between PLR and no-reflow. Moreover, a pooled six-fold increase of no-reflow risk was observed in the high PLR group. Pooled sensitivity and specificity of PLR to predict no-reflow was 65% (CI95%: 61%-69%) and 77% (CI95%: 76%-79%), respectively. The mean pooled of PLR in the no-reflow group was significantly 65.2 (CI95%: 26.7-103.8) units higher than that in the reflow group. The PLR is a significant predictor of no-reflow in STEMI patients subjected to primary PCI which can be used alone or in combination with other markers to identify patients at higher risk of developing no-reflow.

No-reflow is one of the major complications of primary PCI in patients with acute ST elevation myocardial infarction. This phenomenon is associated with adverse outcomes in these patients. In the current study, we evaluated the effectiveness of CHA2DS2-VASc score in predicting no-reflow phenomenon. CHA2DS2-VASc score is a risk stratification method to estimate the risk of thromboembolism in patients with atrial fibrillation.
In total, 396 patients with ST elevation myocardial infarction who had undergone primary PCI were evaluated in our study. Based on post interventional TIMI flow rate results, the patients were divided into two groups: control group (294 patients) and no-reflow group (102 patients). The CHA2DS2-VASc score was calculated for each participant. Multivariate regression analysis was performed to determine the predictive value of this score.
Our findings showed that CHA2DS2-VASc score can predict no-reflow independently (odds ratio: 3.06, 95%, confidence interval: 2.23-4.21, P The CHA2DS2-VASc score could be used as a simple applicable tool in the prediction of no-reflow before primary PCI in the acute ST elevation myocardial infarction patients.