The Systemic Immune Inflammatory Index Predicts No-Reflow Phenomenon after Primary Percutaneous Coronary Intervention in Older Patients with STEMI

Purpose:Coronary no-reflow phenomenon(NRP),a common adverse complication in patients with ST-segment eleva-tion myocardial infarction(STEMI)treated by percutaneous coronary intervention(PCI),is associated with poor patient prognosis.In this study,the correlation between the systemic immune-inflammation index(SII)and NRP in older patients with STEMI was studied,to provide a basis for early identification of high-risk patients and improve their prognosis.Materials and methods:Between January 2017 and June 2020,578 older patients with acute STEMI admitted to the Department of Cardiology of Hebei General Hospital for direct PCI treatment were selected for this retrospective study.Patients were divided into an NRP group and normal-flow group according to whether NRP occurred during the operation.Clinical data and the examination indexes of the two groups were collected.Logistic regression was used to analyze the independent predictors of NRP,and the receiver operating characteristic curve was used to further analyze the ability of SII to predict NRP in older patients with STEMI.Results:Multivariate logistic analysis indicated that hypertension(OR=2.048,95%CI:1.252–3.352,P=0.004),lymphocyte count(OR=0.571,95%CI:0.368–0.885,P=0.012),platelet count(OR=1.009,95%CI:1.005–1.013,P<0.001),hemoglobin(OR=1.015,95%CI:1.003–1.028,P=0.018),multivessel disease(OR=2.237,95%CI:1.407–3.558,P=0.001),and SII≥1814(OR=3.799,95%CI:2.190–6.593,P<0.001)were independent predictors of NRP after primary PCI in older patients with STEMI.Receiver operating characteristic curve analysis demonstrated that SII had a high predictive value for NRP(AUC=0.738;95%CI:0.686–0.790),with the best cut-off value of 1814,a sensitivity of 52.85%and a specificity of 85.71%.Conclusion:For older patients with STEMI undergoing primary PCI,SII is a valid predictor of NRP.

Protective effect of Danhong injection in patients with acute myocardial infarction at a high risk of no-reflow during primary percutaneous coronary intervention

Objective To observe the effect of Danhong injection(DI)in patients with acute ST-segment elevation myocardial infarction(STEMI)at a high risk of no-reflow(NR)during primary percutaneous coronary intervention(PCI).Methods Patients were placed in a DI group and control group.The DI group was given DI and the control group was given physiologic saline.The administration lasted 4 to 6 days in both groups after PCI.Cardiac magnetic resonance(CMR)was carried out during the perioperative period(7±2 days).The primary endpoint of the study was myocardial infarct size(IS)imaged on delayed-enhancement CMR.The secondary endpoint was major adverse cardiac events observed 6 months after PCI.Results In total,160 high-risk NR patients were enrolled,and 110 patients completed the CMR examination.According to postoperative CMR,the Myocardial Salvage Index and left ventricular ejection fraction were higher in the DI group(0.57±0.13 vs.0.48±0.17,P<0.01;49.3%±6.9%vs.46.2%±7.7%,P=0.03,respectively),whereas the IS was lower(19.7%±5.6%vs.22.2%±6.5%,P=0.04),compared with that in the control group.These differences were observed to be significant.After 6 months,the prevalence of major adverse cardiac events in the DI group decreased compared with that in the control group,but the differences were not observed to be significant(P>0.05).Conclusion The application of DI can reduce the myocardial infarct size in STEMI patients at a high risk of NR during primary PCI.

Combination therapy reduces the percutaneous coronary intervention acute myocardial infarction incidence of no-reflow after primary in patients with ST-segment elevation

Background No-reflow is associated with an adverse outcome and higher mortality in patients with ST-segment elevation acute myocardial infarction （STEMI） who undergo percutaneous coronary intervention （PCI） and is considered a dynamic process characterized by multiple pathogenetic components. The aim of this study was to investigate the effectiveness of a combination therapy for the prevention of no-reflow in patient with acute myocardial infarction （AMI） undergoing primary PCI. Methods A total of 621 patients with STEMI who underwent emergency primary PCI were enrolled in this study. Patients with high risk of no-reflow （no-flow score 〉 10, by using a no-flow risk prediction model, n = 216） were randomly divided into a controlled group （n = 108） and a combination therapy group （n = 108）. Patients in the controlled group received conventional treatment, while patients in combination therapy group received high-dose （80 mg） atorvastatin pre-treatment, intracoronary administration of adenosine （140 ~tg/min per kilogram） during PCI procedure, platelet membrane glycoprotein lib/Ilia receptor antagonist （tirofiban, 101.tg/kg bolus followed by 0.15 ~tg/kg per minute） and thrombus aspiration. Myocardial contrast echocardiography was performed to assess the myocardial perfusion 72 h after PCI. Major adverse cardiac events （MACE） were followed up for six months. Results Incidence of no-reflow in combination therapy group was 2.8%, which was similar to that in low risk group 2.7% and was significantly lower than that in control group （35.2%, P 〈 0.01）. The myocardial perfusion （A= 13） values were higher in combination therapy group than that in control group 72 h after PCI. After 6 months, there were six （6.3%） MACE events （one death, two non-fatal MIs and three revasculafizations） in combination therapy group and 12 （13.2%） （four deaths, three non-fatal MIs and five revascularizations, P 〈 0.05） in control group. Conclusions Combination of thrombus aspiration, high-dose statin pre-treatment, intmcoronary administration of adenosine during PCI procedure and platelet membrane glycoprotein Ⅱ b/Ⅲa receptor antagonist reduces the incidence of no-reflow after primary PCI in patients with acute myocardial infarction who are at high risk of no-reflow.

Effects of intracoronary arterial injection of tirofiban on no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention

Objective: To compare the effect of intracoronary arterial injection of tirofiban and sodium nitroprusside (SNP) on no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction (STEMI) underwent primary percutaneous coro-nary intervention (PCI). Methods: A total of 68 patients with acute STEMI who had no-reflow phenomenon during PCI were chosen and randomly divided into SNP group (n = 34) and tirofiban group (n = 34). Aiming at no-reflow phenomenon during PCI, with the use of microcatheters, intracoronary arterial injection of tirofiban was given in tirofiban group, while intracoronary bolus of SNP was given in SNP group. Coronary angiography was conducted to record TIMI flow grade of the infarct-related artery after 10 minutes. Plasma brain natriuretic peptide (BNP) was monitored before and after PCI (in 24 hours). With the help of ultrasound cardiogram, left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic dimension (LVESD) were recorded and compared in 30 days after PCI. Results: The ratio of TIMI grade 3 blood flow in tirofiban group was significantly higher than that in SNP group (76.5% (26/34) vs. 52.9% (18/34), p = .03)BNP levels in two groups had no statistical significance before PCI (p = .16), but in 24 h after PCI, BNP levels in tirofiban group were significantly lower than those in SNP group ((439.00 ± 4.90) μmol/L vs. (632.00 ± 3.63) μmol/L, p = .02)In 30 days after PCI, LVEF, LVEDD and LVESD in tirofiban group were all superior to those in SNP group (all p < .05). Conclusions: Intracoronary arterial injection of tirofiban was superior to SNP in improving no-reflow phenomenon in STEMI patients after PCI in the emergency treatment. Tirofiban therapy can increase coronary blood flow and myocardial perfusion after the occurrence of no-reflow phenomenon during PCI in STEMI patients, and improve long-term prognosis.

No-reflow protection and long-term efficacy for acute myocardial infarction with Tongxinluo： a randomized double-blind placebo- controlled multicenter clinical trial （ENLEAT Trial）

Background No-reflow after emergency percutaneous coronary intervention （PCI） for acute ST segment elevation myocardial infarction （STEMI） is related to the severe prognosis. The aim of this study was to evaluate the efficacy of Tongxinluo, a traditional Chinese medicine, on no-reflow and the infarction area after emergency PCI for STEMI.Methods A total of 219 patients （female 31, 14%） undergoing emergency PCI for STEMI from nine clinical centers were consecutively enrolled in this randomized, double-blind, placebo-controlled, multicenter clinical trial from January 2007 to May 2009. All patients were randomly divided into Tongxinluo group （n=108） and control group （n=111）, given Tongxinluo or placebo in loading dose 2.08 g respectively before emergency PCI with asprin 300 mg and clopidogrel 300 mg together, then 1.04 g three times daily for six months after PCI. The ST segment elevation was recorded by electrocardiogram at hospitalization and 1, 2, 6, 12, 24 hours after coronary balloon dilation to evaluate the myocardial no-flow; myocardial perfusion scores of 17 segments were evaluated on day 7 and day 180 after STEMI with static single-photon emission computed tomography （SPECT） to determine the infarct area.Results There was no statistical significance in sex, age, past history, chest pain, onset-to-reperfusion time, Killip classification, TIMI flow grade just before and after PCI, either in the medication treatment during the follow up such as statin, β-blocker, angiotensin converting enzyme inhibitor （ACEI） or angiotensin receptor blocker （ARB） between two groups. There was significant ST segment restoration in Tongxinluo group compared to the control group at 6 hours （（-0.22±0.18） mV vs. （-0.18±0.16） mV, P=0.0394）, 12 hours （（-0.24 ± 0.18） mV vs. （-0.18±0.15） mV, P=0.0158） and 24 hours （（-0.27±0.16） mV vs. （-0.20±0.16） mV, P=0.0021） reperfusion; and the incidence of myocardial no-reflow was also reduced significantly at 24-hour reperfusion （34.3% vs. 54.1%, P=0.0031）. The myocardial perfusion scores of 17 segments evaluated by static SPECT was improved significantly on day 7 and day 180 after STEMI in Tongxinluo group compared to the control group （0.61±0.40 vs. 0.76±0.42, P=0.0109 and 0.51 ±0.42 vs. 0.66±0.43, P=0.0115, respectively）.There was no significant difference in severe adverse events between two groups.Conclusion Tongxinluo as a kind of traditional Chinese medicine could reduce myocardial no-reflow and infarction area significantly after emergency PCl for STEMI with conventional medicine therapy.

Effect of pre-procedural statin therapy on myocardial no-reflow following percutaneous coronary intervention： a meta analysis

Background Successful revascularization of coronary artery disease, especially ST-elevation myocardial infarction （STEMI）, does not always mean optimal myocardial reperfusion in a portion of patients because of no-reflow phenomenon. We hypothesized that statins might attenuate the incidence of myocardial no-reflow when used before percutaneous coronary intervention （PCI）. The purpose of this study was to summarize the evidence of pre-procedural statin therapy to reduce myocardial no-reflow after PCI. Methods We searched the MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to October 2012 for clinical trials that examined statin therapy before PCI. We required that studies initiated statins before PCI and reported myocardial no-reflow. A DerSimonian-Laird model was used to construct random-effects summary risk ratios. Results In all, 7 studies with 3086 patients met our selection criteria. The use of pre-procedural statins significantly reduced post-procedural no-reflow by 4.2% in all PCI patients （risk ratio （RR） 0.56, 95% confidence interval （CI） 0.35 to 0.90, P=0.016）, and attenuated by 5.0% in non-STEMI patients （RR 0.41, 95% CI 0.18 to 0.94, P=0.035）. This benefit was mainly observed in the early or acute intensive statin therapy populations （RR 0.43, 95% CI 0.26 to 0.71, P=0.001）. Conclusions Acute intensive statin therapy before PCI significantly reduces the hazard of post-procedural no-reflow phenomenon. The routine use of statins before PCI should be considered.

Intracoronary pressure gradient measurement in acute myocardial infarction patients with the no-reflow phenomenon during primary percutaneous coronary intervention

Background:Various experimental and clinical studies have reported on coronary microcirculatory dysfunction("no-reflow"phenomenon).Nevertheless,pathogenesis and effective treatment are yet to be fully elucidated.This study aimed to measure the intracoronary pressure gradient in the no-reflow artery during emergent percutaneous coronary intervention and explore the potential mechanism of no-reflow.Methods:From September 1st,2018 to June 30th,2019,intracoronary pressure in acute myocardial infarction patient was continuously measured by aspiration catheter from distal to proximal segment in the Department of Coronary Care Unit,Tianjin Chest Hospital,respectively in no-reflow arteries(no-reflow group)and arteries with thrombolysis in myocardial infarction-3 flow(control group).At least 12 cardiac cycles were consecutively recorded when the catheter was pulled back.The forward systolic pressure gradient was calculated as proximal systolic pressure minus distal systolic pressure.Comparison between groups was made using the Student t test,Mann-Whitney U-test or Chi-square test,as appropriate.Results:Intracoronary pressure in 33 no-reflow group and 26 in control group were measured.The intracoronary forward systolic pressure gradient was-1.3(-4.8,0.7)and 3.8(0.8,8.8)mmHg in no-reflow group and control group(Z=-3.989,P<0.001),respectively,while the forward diastolic pressure gradient was-1.0(-3.2,0)and 4.6(0,16.5)mmHg in respective groups(Z=-3.851,P<0.001).Moreover,the intracoronary forward pressure gradient showed significant difference between that before and after nicorandil medication(Z=-3.668,P<0.001 in systolic pressure gradient and Z=-3.530,P<0.001 in diastolic pressure gradient).Conclusions:No reflow during emergent coronary revascularization is significantly associated with local hemodynamic abnormalities in the coronary arteries.Intracoronary nicorandil administration at the distal segment of a coronary artery with an aspiration catheter could improve the microcirculatory dysfunction and resume normal coronary pressure gradient.Clinical trial registration:www.ClinicalTrials.gov(No.NCT 03600259).

Cardioprotective effect of liposomal prostaglandin E1 on a porcine model of myocardial infarction reperfusion no-reflow

Objective： To evaluate whether liposomal prostaglandin E1 （lipo-PGE1） can decrease reperfusion no-reflow in a catheter-based porcine model of acute myocardial infarction （AMI）. Methods： Twenty-two male Chinese mini-swines were randomized into three groups： six in a sham-operation group, and eight each in the control and lipo-PGE1 groups. The distal part of the left anterior descending coronary artery （LAD） in the latter two groups was completely occluded for 2 h, and then reperfused for 3 h. Lipo-PGE1 （1 pg/kg） was injected 10 min before LAD occlusion until reperfusion for 1 h in the lipo-PGE1 group. Hemodynamic data and proinflammatory cytokines were examined before AMI, 2 h after occlusion, and 1, 2, and 3 h after reperfusion. Myocardial contrast echocardiography （MCE） and double staining were performed to evaluate the myocardial no-reflow area （NRA）. Results： Left ventricular systolic pressure and end-diastolic pressure significantly improved in the lipo-PGE1 group after reperfusion compared with the control group and also 2 h after AMI （P〈0.05 for both）. MCE and double staining both showed that lipo-PGE1 decreased reperfusion NRA after AMI （P〈0.05, P〈0.01）. Lipo-PGE1 decreased serum interleukin-6 （IL-6） and tumor necrosis factor-a （TNF-a） after myocardial infarction reperfusion （P〈0.05 for both）. Conclusions： Lipo-PGE1 is cardioprotective in our porcine model of myocardial infarction reperfusion no-reflow, decreasing NRA and attenuating the inflammatory response.

The Preventive Effect of Garlicin on A Porcine Model of Myocardial Infarction Reperfusion No-reflow

Objective： To evaluate whether garlicin can prevent reperfusion no-reflow in a catheter-based porcine model of acute myocardial infarction （AMI）. Methods： Twenty-two male Chinese mini swines were randomized into 3 groups： sham-operation group （n=6）, control group （n=8）, and garlicin group （n=8）. The distal part of left anterior descending coronary artery （LAD） in swines of the latter two groups was completely occluded by dilated balloon for 2 h and a successful AMI model was confirmed by coronary angiography （CAG） and electrocardiograph （ECG）, which was then reperfused for 3 h. In the sham-operation group, balloon was placed in LAD without dilatation. Garlicin at a dosage of 1.88 mg/kg was injected 10 min before LAD occlusion until reperfusion for 1 h in the garlicin group. To assess serial cardiac function, hemodynamic data were examined by catheter method before AMI, 2 h after occlusion and 1, 2, and 3 h after reperfusion. Myocardial contrast echocardiography （MCE） and double staining with Evans blue and thioflavin-S were performed to evaluate myocardial no-reflow area （NRA） and risk area （RA）. Results： Left ventricular systolic pressure and left ventricular end-diastolic pressure significantly improved in the garlicin group after reperfusion compared with the control group （P〈0.05） and 2 h after AMI （P〈0.05）. MCE showed garlicin decreased reperfusion NRA after AMI compared with the control group （P〈0.05）. In double staining, NRNRA in the garlicin group was 18.78%, significantly lower than that of the control group （49.84%, P〈0.01）. Conclustions： Garlicin has a preventive effect on the porcine model of myocardial infarction reperfusion no-reflow by improving hemodynamics and decreasing NRA.

Correlation between balloon release pressure and no-reflow in patientswith acute myocardial infarction undergoing direct percutaneouscoronary intervention

Background Balloon release pressure may increase the incidence of no reflow after direct percutaneous coronary intervention(PCI). This randomized controlled study was designed to analyze the correlation between balloon release pressure and no-reflow in patients with acute myocardial infarction(AMI) undergoing direct PCI. Methods There were 156 AMI patients who underwent PCI from January 1, 2010 to December 31, 2012, and were divided into two groups according to the stent inflation pressure: a conventional pressure group and a high pressure group. After PCI, angiography was conducted to assess the thrombolysis in myocardial infarction(TIMI) grade with related artery. Examinations were undertaken on all patients before and after the operation including cardiac enzymes, total cholesterol, low-density lipoprotein, blood glucose, homocysteine, β-thromboglobulin(β-TG), Hamilton depression scale(HAMD) and self-rating anxiety scale(SAS). After interventional therapy, the afore-mentioned parameters in both the conventional pressure group and high pressure group were again analyzed. Results The results showed that CK-MB, HAMD, SAS were significantly different(P <0.05) in all patients after PCI, especially the CK-MB in the high pressure group((25.7±7.6) U/L vs.(76.7±11.8) U/L). CK-MB, HAMD, SAS, and β-TG were comparative before PCI but they were significantly changed(P <0.05) after intervention. No-reflow phenomenon occurred in 13 patients in the high pressure group, which was significantly higher than in the conventional pressure group(17.11% vs. 6.25%, P <0.05). Conclusion In stent implantation, using a pressure less than 1823.4 kPa balloon to release pressure may be the better choice to reduce the occurrence of no-reflow following direct PCI.

Intracoronary nitroprusside in the prevention of the no-reflow phenomenon in acute myocardial infarction

Background No-reflow phenomenon during percutaneous coronary intervention （PCI） for acute myocardial infarction （AMI） is a predictive factor of continuous myocardial ischemia, ventricular remodeling and cardiac dysfunction, which is closely associated with a worse prognosis. This study aimed to evaluate intracoronary nitroprusside in the prevention of the no-reflow phenomenon in AMI.Methods Ninety-two consecutive patients with AMI, who underwent primary PCI within 12 hours of onset, were randomly assigned to 2 groups： intracoronary administration of nitroprusside （group A, n=46）, intracoronary administration of nitroglycerin （group B, n=46）. The angJographic results were observed. The real-time myocardial contrast echocardiography （RT-MCE）, including contrast score index （CSI）, wall motion score index （WMSI）, transmural contrast defect length （CDL） and serious WM abnormal length （WML） were recorded at 24 hours and 1 week post-PCI. High sensitivity C-reactive protein （Hs-CRP） was examined by immune rate nephelometry. N-terminal prohormone brain natriuretic peptide （NT-proBNP） was tested with enzyme-linked immunosorbent assay. Patients were followed up for six months. Major adverse cardiac events （MACE） were recorded. Results The incidence of final TIMI-3 flow in group A was much higher than that in Group B （P 〈0.05）, final corrected TIMI frame count （cTFC） in group A decreased significantly than that in group B （P 〈0.01）. The CSI, CDL/LV length, WMSI and WL/LV length in group A were significantly lower than that in group B （P 〈0.01）. Levels of Hs-CRP and NT-proBNP at 1 week post-PCI decreased significantly in group A than that in group B （P 〈0.01）. Patients were followed up for 6 months and the incidence of MACE in group A was significantly lower than that in group B （P〈0.05）.Conclusion Intracoronary nitroprusside can improve myocardial microcirculation, leading to the decrease of the incidence of no-reflow phenomenon and better prognosis.

Clinical significance of intra-aortic balloon pumping on no-reflow phenomenon of primary percutaneous coronary intervention for acute myocardial infarction

Background Percutaneous coronary intervention （PCI） is used as a treatment for acute myocardial infarction （AMI）, and one of its major complications is the angiographic no-reflow phenomenon （NR）. Although intra-aortic balloon pumping （IABP） is sometimes used in such patients to increase the diastolic coronary blood flow, there is little available information regarding the effects of IABP on the angiographic no-reflow phenomenon. Method Twenty-two AMI patient with NR were performed primary PCI between January 2006 and December 2009, of which 12 patients were selected for IABP therapy and the left 10 were selected as the control group by group procedure of odd and even days; We observed the vasoactive substance in both groups on the days of 1, 2, 3, 5, 7, 10 after the different interventions, which include plasma renin activity （PRA）, angiotensin Ⅱ （ANG Ⅱ）, aldosterone （ALD）, adrenaline （E）, and noradrenalin （NE）; In addition, cardiac structure and cardiac ventricle systolic function including left atrium medial diameter （LAMD）, left ventricular medial diameter （LVMD） Finally, left ventricular ejection fraction （LVEF） were evaluated after 10 days, 3 months and 6 months; statistics was taken to analysis. Results According to the time concentration curve, vasoactive substance of the IABP group decreased faster than that of the control group, and this difference had statistical significance （P 〈 0.01 ） ; In terms of LAMD, LVMD, and LVEF, echocardiography difference of the IABP and the control group in 10 days, 3 months, and 6 months also showed statistical significance （P 〈 0.05）. Conclusions IABP can significantly reduce the release of vasoactive substances of NR in patients of primary PCI for AMI; LAMD, LVMD and LVEF in 10 days, 3 months, and 6 months can be improved using this method, which is conducive to recovery of heart function.

Application of intra-aortic balloon pumping on no-reflow phenomenon in primary PCI for STEMI

Background To investigate the effect of intra-aortic balloon pumping （IABP） on no-reflow phenomenon primary percutaneous coronary intervention （PCI） for ST-Elevation Myocardial Infarction （STEMI）. Methods Clinical data of 22 acute myocardial infarction patients after PCI with angiographic no-reflow phenomenon were retrospectively analyzed between January 2006 and December 2009.12 patients underwent IABP, other 10 patients as control group. We observed difference of cardiac structure, brain natriuretic peptide （BNP） and ventricular systolic function between two group, as well as cardiac injury markers （MYO,CK-MB, cTnI） in both groups on the days of 1, 2, 3, 5, 7, 10 after the different interventions. In addition, cardiac structure and ventricular systolic function including left atrium medial diameter （LAMD）, left ventricular medial diameter （LVMD）, left ventricular ejection fraction （LVEF） was evaluated after 10 days, 3 months,6 months Finally, statistics was used to analysis the data. Results The several vasoactive substances as well as cardiac injury markers and LAMD, LVMD, LVEF of 10 days, 3 months, 6 months of IABP group were significant difference with control group significant difference （P 〉 0.0 PCI with angiographic no-reflo （P 〈 0.05）. 5）. Conclusions w phenomenon, BNP targets of IABP group compared with the control group no IABP has effects on prognosis in STEMI patients who performed which is conducive to recovery of heart function.

Feasibility of lymphocyte-to-monocyte ratio in predicting no-reflow phenomenon in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background The no-reflow phenomenon is correlated with adverse effects on short-term and long-term outcomes of ST-elevation myocardial infarction(STEMI) in patients undergoing primary percutaneous coronary intervention(PCI). The lymphocyte-to-monocyte ratio(LMR) is a novel inflammatory marker which is associated with slow coronary flow. We aimed to investigate the predictive value of LMR for no-reflow phenomenon in patients with STEMI undergoing primary PCI. Methods A total of 1350 STEMI patients were enrolled in this study from January 2014 to January 2018. Blood samples were obtained at initial admission for analysis of LMR.The univariate and multivariate logistic regression analysis was performed to study the relationship between LMR and no-reflow phenomenon. Results All the 156 patients among the study population suffered from no-reflow phenomenon during the procedure. The LMR level was significantly lower in patients with no-reflow(1.6 ±1.0 vs. 3.25 ± 1.8, P<0.001). Multivariate logistic regression analysis showed that LMR was independently associated with no-reflow post primary PCI in STEMI patients.(OR 2.356, 95% CI 1.201-5.945;P=0.030). The area under the ROC curve for the LMR was 0.757 [95% confidence interval(CI) 0.686-0.828, P<0.001]. Conclusions LMR at admission could serve as a biomarker for no-reflow phenomenon in patients undertaken primary PCI for STEMI.[S Chin J Cardiol 2019;20(4):228-235]

冠心病介入治疗中的无血流现象及处理

目的 评价血小板表面糖蛋白受体 (GPⅡb/Ⅲa)拮抗剂ReoPro对硝酸甘油不能缓解的冠状动脉无血流现象(No -Reflow)的疗效以及对住院期间临床预后的影响。方法 回顾性研究了伴或不伴No -Reflow现象病人的临床特点、住院期间主要心血管事件 (死亡、心肌梗死、血管再通术 )发生率。结果 10 93例病人中经皮球囊扩张术 (PTCA) 35 2例 ,支架术 741例 ;共 2 3例病人被描述有No -Reflow现象 ,其中 6例病人对硝酸甘油冠状动脉内注射无反应 ,在给予ReoPro后TIMI血流明显改善 (0 83± 0 41vs 2 5 0± 0 5 4,P <0 0 0 2 ) ,与同期不伴有No -Reflow现象相比 ,住院期间死亡 (0vs 0 74% ,P >0 75 )、靶血管再介入 (0vs 1 10 % ,P >0 75 )、搭桥术 (0vs 0 2 1% ,P >0 90 )发生率无区别 ,但心肌梗死发生率较高 (Q波心肌梗死 :16 7%vs0 37% ,P <0 0 0 5 ;无Q波心肌梗死 :5 0 %vs 1 0 5 % ,P <0 0 0 5 )。结论 ReoPro能明显改善对硝酸甘油无反应No -Reflow病人的TIMI血流及临床预后 ,也提示血小板介导的微血管血栓及栓塞是这类病人No

Thrombus aspiration in acute myocardial infarction:Rationale and indication

Reperfusion of myocardial tissue is the main goal of primary percutaneous coronary intervention(PPCI) with stent implantation in the treatment of acute ST-segment elevation myocardial infarction(STEMI). Although PPCI has contributed to a dramatic reduction in cardiovascular mortality over three decades, normal myocardial perfusion is not restored in approximately one-third of these patients. Several mechanisms may contribute to myocardial reperfusion failure, in particular distal embolization of the thrombus and plaque fragments. In fact, this is a possible complication during PPCI, resulting in microvascular obstruction and no-reflow phenomenon. The presence of a visible thrombus at the time of PPCI in patients with STEMI is associated with poor procedural and clinical outcomes. Aspiration thrombectomy during PPCI has been proposed to prevent embolization in order to improve these outcomes. In fact, the most recent guidelines suggest the routine use of manual aspiration thrombectomy during PPCI(class Ⅱa) to reduce the risk of distal embolization. Even though numerous international studies have been reported, there are conflicting results on the clinical impact of aspiration thrombectomy during PPCI. In particular, data on long-term clinical outcomes are still inconsistent. In this review, we have carefully analyzed literature data on thrombectomy during PPCI, taking into account the most recent studies and meta-analyses.

Clinical and procedural predictors of no-ref low in patients with acute myocardial infarction after primary percutaneous coronary intervention

BACKGROUND: The treatment of acute myocardial infarction(AMI) is thought to restore antegrade blood flow in the infarct-related artery(IRA) and minimize ischemic damage to the myocardium as soon as possible. The present study aimed to identify possible clinical predictors for no-refl ow in patients with AMI after primary percutaneous coronary intervention(PCI).METHODS: A total of 312 consecutive patients with AMI who had been treated from January 2008 to December 2010 at the Cardiology Department of East Hospital, Tongji University School of Medicine were enrolled in this study. Inclusion criteria were:(i) patients underwent successfully primary PCI within 12 hours after the appearance of symptoms; or(ii) patients with ischemic chest pain for more than 12 hours after a successful primary PCI within 24 hours after appearance of symptoms. Exculsion criteria were:(i) coronary artery spasm;(ii) diameter stenosis of the culprit lesion was ≤50% and coronary blood f low was normal;(iii) patients with severe left main coronary or multivessel disease, who had to require emergency revascularization. According to thrombolysis in myocardial infarction(TIMI), the patients were divided into a reflow group and a no-reflow group. The clinical data, angiography f indings and surgical data were compared between the two groups. Univariate and multivariate logistic regressions were used to determine the predictors for no-ref low.RESULTS: Fifty-four(17.3%) of the patients developed NR phenomenon after primary PCI. Univariate analysis showed that age, time from onset to reperfusion, systolic blood pressure(SBP) on admission, Killip class of myocardial infarction, intra-aortic balloon pump(IABP) use before primary PCI, TIMI flow grade before primary PCI, type of occlusion, thrombus burden on baseline angiography, target lesion length, reference luminal diameter and method of reperfusion were correlated with no-reflow(P<0.05 for all). Multiple logistic regression analysis identified that age >65 years [OR=1.470, 95% confi dence interval(CI) 1.460–1.490, P=0.007], long time from onset to reperfusion >6 hours(OR=1.270, 95%CI 1.160–1.400, P=0.001), low SBP on admission <100 mmHg(OR=1.910, 95%CI 1.018–3.896, P=0.004), IABP use before PCI(OR= 1.949, 95%CI 1.168–3.253, P=0.011), low(≤1) TIMI fl ow grade before primary PCI(OR=1.100, 95%CI 1.080–1.250, P<0.001), high thrombus burden(OR=1.600, 95%CI 1.470–2.760, P=0.030), and long target lesion(OR=1.948, 95%CI 1.908–1.990, P=0.019) on angiography were independent predictors of no-refl ow.CONCLUSION: The occurrence of no-refl ow after primary PCI for acute myocardial infarction can predict clinical, angiographic and procedural features.

Temporal alterations in pericytes at the acute phase of ischemia/reperfusion in the mouse brain

Pericytes,as the mural cells surrounding the microvasculature,play a critical role in the regulation of microcirculation;however,how these cells respond to ischemic stroke remains unclear.To determine the temporal alterations in pericytes after ischemia/reperfusion,we used the 1-hour middle cerebral artery occlusion model,which was examined at 2,12,and 24 hours after reperfusion.Our results showed that in the reperfused regions,the cerebral blood flow decreased and the infarct volume increased with time.Furthermore,the pericytes in the infarct regions contracted and acted on the vascular endothelial cells within 24 hours after reperfusion.These effects may result in incomplete microcirculation reperfusion and a gradual worsening trend with time in the acute phase.These findings provide strong evidence for explaining the“no-reflow”phenomenon that occurs after recanalization in clinical practice.

Effects of post-dilation on coronary blood flow and MACE events following primary percutaneous coronary intervention in patients with STEMI

Objective:This retrospective cohort study aimed to evaluate the effect of post-dilation on coronary blood flow and MACE events during hospitalization and 1 year follow-up following primary PCI in patients with ST-segment.Methods:419 eligible patients who underwent PPCI due to STEMI between January 2015 and October 2019 were enrolled.The CTFC,final QCA,and the incidence of no-reflow/slow-flow during different procedure moments were assayed.Study end points was to compare two groups of patients with clinical characteristics,compared two groups of patients with the incidence of no-reflow and slow-flow,and the incidence of MACE during hospitalization and 1-year follow-up.Results:The incidence of final no-reflow/slow-flow in the post-dilation group was not significantly higher than that in the non-post-dilation group(24.3%vs.19.4%;p=0.238).There was no significant statistical difference in MACE events during hospitalization,but for the 1-year follow-up,the incidence of Target vessel revascularization and Target lesion revascularization in the post-dilation group was lower than that in the non-post-dilation group.A multivariable logistic regression model revealed that age(OR=1.078,95%CI=1.038-1.120;P<0.001),history of diabetes(OR=3.009,95%CI=1.183-7.654;P=0.021),post-dilation(OR=0.192,95%CI=0.067-0.549;P=0.002)were independently correlated with long-term follow-up of MACE.Conclusion:Post-dilation does not increase poor prognosis during hospitalization,and reduces the incidence of TVR and TLR events during long-term follow-up.

Myocardial Infarction: An Overview of STEMI and NSTEMI Physiopathology and Treatment

Patients with myocardial infarction resulting from acute coronary syndrome are classified by electrocardiographic presentation: 1-acute ST-segment elevation myocardial infarction (STEMI) or 2-non-ST-segment elevation myocardial infarction (NSTEMI). Prompt reperfusion of an infarct-related artery by percutaneous coronary interventions provides some relief of symptoms;long-term prognosis appears to be worse in STEMI compared to NSTEMI patients but clinical findings remain controversial. Reduced myocardial perfusion to the infarct area, caused in part by microvascular obstruction, is a privileged target for diverse pharmacologic or non-pharmacologic interventions (or combinations thereof) to improve clinical outcomes. To date, benefits of both pharmacologic and non-pharmacologic strategies to either limit microvascular obstruction and myocardial injury or improve myocardial perfusion are inconsistent. This review focuses on the physiopathological aspects of myocardial infarction in relation to development of STEMI/NSTEMI and on potential cardioprotective strategies.