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Published on: May 28, 2019
Pharmacological management of no reflow during percutaneous coronary intervention
Italo Porto1, Vaishali Ashar, Andrew R J Mitchell
1Department of Cardiology, John Radcliffe Hospital, Oxford, UK.
Insights
Angiographic no reflow, a reduction in coronary blood flow during percutaneous coronary intervention (PCI), can occur without clear blockages. Management strategies are multifactorial, involving vasodilators and glycoprotein IIb/IIIa inhibitors.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Biology
Background:
- Angiographic no reflow is a recognized complication of percutaneous coronary intervention (PCI).
- It is characterized by reduced epicardial coronary blood flow without identifiable dissection or obstruction.
- No reflow is frequently observed in PCI for acute myocardial infarction and saphenous vein graft occlusions.
Purpose of the Study:
- To review the pathogenesis of reduced epicardial flow during PCI.
- To focus on drugs studied for the treatment of no reflow phenomenon.
- To identify potential therapeutic conclusions from published evidence.
Main Methods:
- Review of existing literature on angiographic no reflow.
- Analysis of pharmacological agents used in managing no reflow.
- Examination of theoretical causes including microembolic and humoral effects.
Main Results:
- The exact mechanism of no reflow remains unknown, with theories pointing to microcirculatory dysfunction.
- Pharmacological management includes vasodilators (e.g., nitrates, verapamil, adenosine) and potentially vasoconstrictors (e.g., epinephrine).
- Glycoprotein IIb/IIIa inhibitors show promise, particularly via intracoronary administration, for their de-thrombotic effects.
Conclusions:
- No reflow is a complex condition requiring multifactorial therapeutic strategies.
- While various agents are used, no double-blind randomized trials have established optimal treatments or dosages.
- Published evidence suggests potential benefits from vasodilators and glycoprotein IIb/IIIa inhibitors.
Abstract:
Angiographic no reflow is a recognized phenomenon during percutaneous coronary intervention (PCI). It usually follows successful lesion dilation and, by definition, it represents a reduction in epicardial coronary blood flow in the absence of identifiable dissection, obstruction or distal vessel cut off (indicative of distal embolisation). No reflow appears to be more commonly associated with PCI for acute myocardial infarction and PCI for saphenous vein graft occlusions. While the exact mechanism of no reflow is unknown, theoretical causes include local humoral and microembolic effects leading to microcirculatory dysfunction. As the process is multifactorial, various therapeutic strategies are required in different situations. The present day pharmacological management involves the use of vasodilators including nitrates, verapamil, papaverine, adenosine, nicardipine and sodium nitroprusside, but interestingly a vasoconstrictor like epinephrine may also have a role. Glycoprotein IIb/IIIa platelet receptors antagonist have shown a powerful de-thrombotic effect, and the intracoronary administration appears to be particularly promising. We review the pathogenesis of a reduced epicardial flow during PCI and focus on those drugs that have been studied for the treatment of no reflow. Although no double blind, randomized trial has been conducted to assess any of these agents, or to determine the appropriate dosage, we try to identify some useful conclusions from the published evidence.
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