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No-reflow: incidence and detection in the cath-lab
Giampaolo Niccoli1, Nicola Cosentino, Cristina Spaziani
1Institute of Cardiology, Catholic University of the Sacred Heart, Largo Agostino Gemelli, 8, 00168, Rome, Italy. gniccoli73@hotmail.it
Insights
Myocardial no-reflow, a persistent microcirculatory issue after ST-elevation myocardial infarction (STEMI) treatment, indicates a poorer prognosis. This review covers key indexes for assessing no-reflow in the cath-lab and post-procedure.
Area of Science:
- Cardiology
- Interventional Cardiology
- Microcirculation Research
Background:
- ST-elevation myocardial infarction (STEMI) treatment aims to restore blood flow.
- Microcirculatory impairment, termed "myocardial no-reflow," can persist post-recanalization.
- No-reflow is linked to adverse short- and long-term outcomes in STEMI patients.
Purpose of the Study:
- To review and discuss various indexes used to assess myocardial no-reflow.
- To highlight methods for no-reflow detection both during cardiac catheterization and post-procedure.
- To emphasize the clinical significance of no-reflow in STEMI management.
Main Methods:
- Review of established and emerging indexes for no-reflow assessment.
- Categorization of indexes based on assessment timing (in-cath-lab vs. post-cath-lab).
- Inclusion of both traditional and advanced diagnostic techniques.
Main Results:
- No-reflow incidence varies (5-50%) based on patient population and detection methods.
- In-cath-lab assessments include TIMI flow grade, TIMI frame count, myocardial blush grade, and coronary flow.
- Post-cath-lab monitoring utilizes ST-segment resolution and advanced imaging (echocardiography, MRI).
Conclusions:
- Accurate assessment of no-reflow is crucial for predicting STEMI patient prognosis.
- A combination of in-cath-lab and post-procedure monitoring provides comprehensive evaluation.
- Further research into novel no-reflow indexes may improve patient outcomes.
Abstract:
The primary goal in patients with ST-elevation myocardial infarction (STEMI) is the restoration of myocardial tissue-level perfusion. In a variable proportion of patients with STEMI, however, microcirculatory impairment may persist after epicardial coronary artery recanalization. This phenomenon is known as "myocardial no-reflow". Of note, no-reflow is associated with a worse prognosis both at short- and long-term follow-up. Depending on the population under study and the diagnostic technique used for its detection, the incidence of no-reflow ranges from 5 to 50%. No-reflow can be directly assessed in the cath-lab in several ways, including angiographic Thrombolysis in Myocardial Infarction (TIMI) flow grade assessment and more complex angiographic indexes, such as TIMI frame count, TIMI perfusion grade, myocardial blush grade, or by direct invasive assessment of coronary flow. After the cath-lab, both the evaluation of electrocardiographic ST-segment resolution and imaging techniques, as myocardial contrast echocardiography or cardiac magnetic resonance, are able to monitor no-reflow evolution, with imaging playing a crucial role in its quantification. In this article, we review indexes of no-reflow used both in the cath-lab and thereafter.
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