Analysis of correlative factors of female coronary slow-flow phenomenon: A retrospective study.

The coronary slow-flow phenomenon (CSFP) is a manifestation of coronary artery disease wherein coronary angiography reveals no apparent stenosis; however, there is a delay in blood flow perfusion. Given its increased occurrence in male patients, with the majority of subjects in previous studies being male, this study aimed to explore whether distinct risk factors are present in female patients with CSFP. This single-center retrospective study focused on female patients diagnosed with CSFP by using coronary angiography. Eligible patients meeting the predefined inclusion and exclusion criteria were divided into the study group (presenting with CSFP) and control group (displaying normal epicardial coronary arteries). Comparative analyses of clinical and diagnostic data were performed. Ninety-two patients with CSFP and an equal number of controls were enrolled in this study. Patients with CSFP exhibited a higher prevalence of smokers (P = .017) and a heightened incidence of diabetes mellitus (DM) (P = .007). Significantly elevated levels of total cholesterol (TC) (P = .034) and free fatty acids (FFA) (P = .016) were observed in the CSFP group compared to those in the control group. Additionally, patients with CSFP displayed lower levels of apolipoprotein E (ApoE) (P = .092), free thyroxine (FT4) (P = .001), and total thyroxine (TT4) (P = .025). Logistic regression analysis indicated that smoking (P = .019), FFA (P < .001), ApoE (P = .015), and FT4 (P < .001) were independent risk factors for CSFP, accounting for confounding factors. Additionally, the area under the ROC curve (AUC) of the combined effect of smoking, ApoE, FT4, and FFA on CSFP was 0.793 (95% CI: 0.729-0.857, P < .01). In addition to the established risk factors for smoking, diabetes, and hyperlipidemia, female patients with CSFP exhibited significant differences in apoE, FFA, FT4, and TT4 levels compared to the control group. Smoking, FFA, and FT4 levels emerged as independent risk factors for CSFP.

No reflow phenomenon in CAD patients after percutaneous coronary intervention: A prospective hospital based observational study.

The present study assessed incidence, risk factors, in-hospital and short-term outcomes associated with no-reflow in patients undergoing percutaneous coronary intervention (PCI) in STEMI, NSTEMI, unstable angina and stable angina. Out of 449 patients, 42 (9.3%) developed no-reflow. Hypertension, dyslipidemia, obesity and smoking were significant risk factors. There was significant association of no-reflow with left main disease, multiple stents, target lesion length≥ 20 mm and higher thrombus grade. Interestingly, 93 patients (23.4%) of normal flow had myocardial perfusion grade (MPG) of 0/1 with mortality in 9 (10%) patients. No-reflow is associated with poor in-hospital and short-term outcomes with higher incidence of death, cardiogenic shock, heart failure and MACE. Knowledge of risk factors of no-reflow portends a more meticulous approach to improve final outcomes. MPG could be better predictor of outcomes in these patients.

Echocardiographic and laboratory findings in coronary slow flow phenomenon: cross-sectional study and review.

BACKGROUND: Coronary sow-flow phenomenon (CSFP) is defined as slow passage of the contrast injected into the coronary arteries without distal obstruction of the vessel. METHODS: The present study was a cross-sectional, descriptive-analytical study performed at the Seyed-al-Shohada Heart Center during 2018-2019. The eligible patients based on the inclusion and exclusion criteria were divided into the study group showing the CSFP and the control group with normal epicardial coronary arteries. RESULTS: The study included 124 patients. 67.9% of the study group and 39.4% of the control group were male patients (p-value = 0.001), and the mean patient age was 52.18 ± 12.55 and 51.77 ± 10.36 years in the study and control groups, respectively (p-value = 0.18). The study group had a significantly higher BMI than the control group (p < 0.05) and also a higher prevalence of smoking and hypertension. The variables of ALC, Hct, Plt, MPV, RDW, Cr, triglyceride, TC, and LDL, were higher in the study group. Given the echocardiographic findings, the mean E wave was significantly lower in the study group, while the control group had a significantly higher GLS (p-value = 0.01). Also, left anterior descending artery was the most common artery involved with CSFP. CONCLUSION: The CSFP was significantly more common in men, smokers, hypertensive patients, and patients with high BMI. Moreover, these patients had significantly higher platelet count, MPV, LDL, and FBS. Some other laboratory variables were also higher in these patients. Given the echocardiographic findings, mild diastolic dysfunction and low GLS were also observed in the study group.

Slow Coronary Flow: Pathophysiology, Clinical Implications, and Therapeutic Management.

Coronary slow flow (CSF) is an angiographic phenomenon with specific epidemiologic characteristics, associated clinical presentation, and prognosis. Although patients with CSF are diagnosed as having "normal coronary arteries," it seems appropriate to consider CSF as a distinct disease entity requiring specific treatment. The patient with CSF is usually male, smoker, obese, with a constellation of risk factors suggestive of metabolic syndrome. Unstable angina is the most common clinical presentation, with recurrent episodes of chest pain at rest associated with electrocardiographic changes often requiring readmission and reevaluation. Regarding definition and diagnosis, interventionists should first exclude possible "secondary" causes of CSF, use objective means for definition and then differentiate from other similar conditions such as microvascular angina. Although the phenomenon is generally benign, patients with CSF are severely symptomatic with recurrent episodes of chest pain and poor quality of life. Furthermore, acute presentation of the phenomenon is commonly life-threatening with ventricular tachyarrhythmias, conduction abnormalities, or cardiogenic shock. Acute treatment of CSF includes, but is not restricted to, intracoronary infusion of dipyridamole, adenosine, or atropine. Chronic management of patients with CSF encompasses dipyridamole, diltiazem, nebivolol, telmisartan, and/or atorvastatin associated with amelioration of angina symptoms, improved quality of life, and good prognosis.

Desfechos em Pacientes com Fenômeno de No-Reflow Coronário e a Relação entre a Molécula-1 de Lesão Renal e o Fenômeno de No-Reflow Coronário / Outcomes in Coronary No-Reflow Phenomenon Patients and the Relationship between Kidney Injury Molecule-1 and Coronary No-Reflow Phenomenon

Resumo Fundamento O fenômeno de no-reflow coronário (CNP, do inglês Coronary no-reflow phenomenon) está associado a um risco aumentado de eventos cardiovasculares adversos maiores (ECAM). Objetivo Este estudo teve como objetivo avaliar a relação entre os níveis séricos da Molécula-1 de lesão renal (KIM-1) e o CNP em pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Métodos Este estudo incluiu um total de 160 pacientes (113 homens e 47 mulheres; média de idade: 61,65 ± 12,14 anos) com diagnóstico de IAMCSST. Os pacientes foram divididos em dois grupos, o grupo reflow (GR) (n = 140) e o grupo no-reflow (GNR) (n = 20). Os pacientes foram acompanhados durante um ano. Um valor de p<0,05 foi considerado significativo. Resultados O CNP foi observado em 12,50% dos pacientes. O nível de KIM-1 sérico foi significativamente maior no GNR do que no GR (20,26 ± 7,32 vs. 13,45 ± 6,40, p<0,001). O índice de massa corporal (IMC) foi significativamente maior no GNR do que no GR (29,41 (28,48-31,23) vs. 27,56 (25,44-31,03), p=0,047). A frequência cardíaca (FC) foi significativamente menor no GNR do que no GR (61,6 ± 8,04 vs. 80,37 ± 14,61, p<0,001). O escore do European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) foi significativamente maior no GNR do que no GR (3,06 ± 2,22 vs. 2,36 ± 2,85, p=0,016). A incidência de AVC foi significativamente maior no GNR do que no GR (15% vs. 2,90%, p=0,013). O nível basal de KIM-1 (OR = 1,19, IC 95%: 1,07-1,34, p=0,002) e HR (OR = 0,784, IC 95%: 0,69-0,88, p<0,001) foram os preditores independentes de CNP. Conclusão Em conclusão, os níveis séricos basais de KIM-1 e a FC mais baixa estão independentemente associados com CNP em pacientes com IAMCSST, e o acidente vascular cerebral foi significativamente maior no GNR em um ano de seguimento. (Arq Bras Cardiol. 2021; 116(2):238-247)

Abstract Background Coronary no-reflow phenomenon (CNP) is associated with an increased risk of major cardiovascular adverse events (MACE). Objective This study aimed to evaluate the relationship between serum Kidney Injury Molecule-1 (KIM-1) levels and CNP in patients with acute ST-segment elevation myocardial infarction (STEMI). Methods This study included a total of 160 patients (113 males and 47 females; mean age: 61.65±12.14 years) who were diagnosed with STEMI. The patients were divided into two groups, the reflow group (RG) (n=140) and the no-reflow group (NRG) (n=20). Patients were followed during one year. A p-value of <0.05 was considered significant. Results CNP was observed in 12.50% of the patients. Serum KIM-1 was significantly higher in the NRG than in the RG (20.26±7,32 vs. 13.45±6.40, p<0.001). Body mass index (BMI) was significantly higher in the NRG than in the RG (29.41 (28.48-31.23) vs. 27.56 (25.44-31.03), p=0.047). Heart rate (HR) was significantly lower in the NRG than in the RG (61.6±8.04 vs. 80.37±14.61, p<0.001). The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) was significantly higher in the NRG than in the RG (3.06±2.22 vs. 2.36±2.85, p=0.016). The incidence of stroke was significantly higher in the NRG than in the RG (15% vs. 2.90%, p=0.013). The baseline KIM-1 level (OR=1.19, 95% CI:1.07 to 1.34, p=0.002) and HR (OR=0.784, 95% CI:0.69 to 0.88, p<0.001) were the independent predictors of CNP. Conclusion In conclusion, baseline serum KIM-1 concentrations and lower HR are independently associated with CNP in STEMI patients and the incidence of stroke was significantly higher in the NRG in the one-year follow-up. (Arq Bras Cardiol. 2021; 116(2):238-247)

Atrial Fibrillation: A Novel Risk Factor for No-Reflow Following Primary Percutaneous Coronary Intervention.

There is a lack of evidence regarding the association of atrial fibrillation (AF) and no-reflow (NR) phenomenon in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (pPCI). A total of 2452 patients with STEMI who underwent pPCI were retrospectively investigated. After exclusions, 370 (14.6%) patients were in the AF group and 2095 (85.4%) were in the No-AF group. Patients with a thrombolysis in myocardial infarction flow rate <3 were defined as having NR. Patients in the AF group were older and had higher 3-vessel disease rates (24.1% vs 18.9%; P = .021) and lower left ventricular ejection fraction (45.4 [11.7] vs 48.7 [10.5%]; P < .001). No-reflow rates were higher in the AF group than in the No-AF group (29.1% vs 11.8%; P < .001). According to multivariable analysis, AF (odds ratio: 1.81, 95% confidence interval: 1.63-2.04, P < .001), age, Killip class, anterior myocardial infarction, diabetes mellitus, chronic kidney disease, stent length, and smoking were independent predictors of NR following pPCI. Atrial fibrillation is a quite common arrhythmia in patients with STEMI. Atrial fibrillation was found to be an independent predictor of NR in the current study. This effect of AF on coronary flow rate might be considered as an important risk factor in STEMI.

Association between the No-Reflow Phenomenon and Soluble CD40 Ligand Level in Patients with Acute ST-Segment Elevation Myocardial Infarction.

Background and objectives: No-reflow (NR) phenomenon is defined as insufficient myocardial perfusion in coronary circulation in the absence of angiographic evidence of mechanical obstruction. The primary mechanisms of the NR occurrence are thought to be high platelet activity and thrombus burden. Soluble CD40 ligand (sCD40L), which is released into the plasma following platelet activation, accelerates the inflammatory process and causes further platelet activation. The aim of our study is to investigate the relationship between the NR phenomenon and sCD40L level in patients with ST-elevation myocardial infarction (STEMI). Methods: A total of 81 acute STEMI patients undergoing primary percutaneous coronary intervention and 40 healthy participants were included in this study. Acute STEMI patients were classified into two groups: 41 patients with the NR phenomenon (NR group) and 40 patients without the NR phenomenon (non-NR group). The serum sCD40L level was measured for all groups. Results: The serum sCD40L level was significantly higher in the NR group than in non-NR and control groups (379 ± 20 pg/mL, 200 ± 15 pg/mL and 108 ± 6.53 pg/mL, respectively; p < 0.001). Univariate regression analysis demonstrated that male sex, age, Gensini score and sCD40L level were the possible factors affecting the occurrence of the NR phenomenon. In multivariate regression analysis, age (odds ratio [OR], 1.091; 95% confidence interval [CI], 1.023-1.163; p < 0.008) and serum sCD40L (OR, 1.016; 95% CI, 1.008-1.024; p < 0.001) remained the independent predictor of the presence of NR. Conclusions: Our study showed that serum sCD40L level was an independent predictor of the NR phenomenon occurrence.

Risk factors and angiographic profile of coronary slow flow (CSF) phenomenon in North Indian population: An observational study.

BACKGROUND: "Coronary slow flow'' (CSF) is delayed vessel opacification in the absence of epicardial stenosis. Studies in different ethnic groups have found variable risk factors associated with CSF. AIM: of present study was to analyze the risk factors and angiographic profile of CSF in North Indian population, not studied till date. METHODS: 40 patients with CSF and 40 controls were studied. CSF was determined quantitatively by thrombolysis in myocardial infarction (TIMI) frame count method. Various clinical risk factors (age, sex, body mass Index (BMI), diabetes, hypertension, dyslipidemia, smoking), hematological and biochemical parameters (hematocrit, platelet count, uric acid, homocysteine, fibrinogen, high sensitivity C reactive protein (hsCRP), glycosylated hemoglobin (HbA1c) were assessed. RESULTS: Of the 40 patients with CSF, 37 (92.5%) were males. While 20 patients (50%) presented with chronic stable angina, rest 20 (50%) presented with acute coronary syndrome. [15 (37.5%) with unstable angina and 5 (12.5%) with non ST elevation myocardial infarction (NSTEMI)]. Patients with CSF had significantly higher BMI (27.27±2.82 vs. 24.12±2.35, p<0.001), fibrinogen levels (398.48±120.96 vs. 331.55±162.6, p=0.04) and smoking (24(60.0%) vs 14(35.0%), p=0.02). On multivariable regression analysis, only BMI was found to have an independent association with CSF (odds ratio 1.613, 95% confidence interval 1.265-2.057, p<0.001). CONCLUSION: This is the first study to analyze clinical presentation, angiographic profile and risk factors associated with CSF in North Indian population. In this study, we found only BMI to have an independent association with CSF.

Usefulness of The C-Reactive Protein/Albumin Ratio for Predicting No-Reflow in ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: The ratio of serum C-reactive protein (CRP) to albumin has been proven to be a more accurate indicator than albumin and CRP levels alone in determining the prognosis of patients with cancer and critical illness. The aim of this study was to determine whether the CRP/albumin ratio (CAR) can be linked to imperfect reperfusion that can worsen the prognosis of ST-elevation myocardial infarction (STEMI) in patients treated with primary percutaneous coronary intervention (pPCI). MATERIALS AND METHODS: A total of 1217 consecutive STEMI patients who achieved epicardial vessel patency with pPCI were recruited to this study. RESULTS: The study population was divided into 2 groups: reflow (n = 874) and no-reflow (NR) (n = 343) groups. The white blood cell count (WBC), neutrophil-to-lymphocyte ratio (NLR) and CAR (0.03 [0.01-0.04] vs 0.06 [0.03-0.12] (P < .001) were significantly higher in the NR group than in the reflow group, and these factors were found to be independent predictors of NR development. The best cut-off value of CAR predicting NR was 0.59 with a sensitivity of 54.7% and specificity of 86.7. The predictive power of CAR surpassed that of CRP, albumin, WBC count and NLR in the receiver operator curve (ROC) curve comparison. CONCLUSION: No-reflow can be predicted by systemic inflammation markers including WBC count, NLR and CAR measured from the blood sample obtained on admission. CAR has a higher clinical value than CRP, albumin level, WBC count and NLR in NR prediction.

Clinical, demographic, risk factor and angiographic profile of coronary slow flow phenomenon: A single centre experience.

BACKGROUND: The coronary slow flow phenomenon (CSFP) is an angiographic finding characterized by delayed distal vessel opacification in the absence of significant epicardial coronary stenosis. Although it is well-known to interventional cardiologists for approximately four decades, the etiopathogenesis still remains unclear. AIMS AND OBJECTIVES: In this study, we aimed to determine the clinical, demographic, risk factor and angiographic profile of patients with CSFP. METHODS: Clinical, demographic, risk factor and angiographic profile were recorded in all consecutive patients who had undergone coronary angiography between September 2016 and March 2017 and showed features of CSFP and a control group who showed normal coronary flow (NCF). The CSFP was diagnosed on the basis of the corrected thrombolysis in myocardial infarction frame count. RESULTS: CSFP was significantly more prevalent in male patients. Among the traditional risk factors, there was significantly more prevalence of hypertension (31.25% versus 6.67%, p < 0.001), dyslipidemia (40% versus 7.5%, p < 0.001) and history of tobacco use (47.5% versus 10.0%, p < 0.001) in CSFP patients as compared to NCF patients. On multivariable regression analysis hypertension, dyslipidemia, history of smoking and tobacco chewing were found to have independent association with CSFP. Acute coronary syndrome (ACS) was the most common mode of presentation in CSFP patients. CONCLUSION: CSFP was relatively common among patients who presented with ACS. Hypertension, dyslipidemia, smoking and tobacco chewing can be considered independent risk factors for this phenomenon. Therefore, CSFP should be considered as a pathological entity and not an entirely benign condition.

Clinical and laboratory predictors of coronary slow flow in coronary angiography.

BACKGROUND: The coronary slow-flow phenomenon (CSFP) is a multifactorial angiographic finding with no established pathogenesis. OBJECTIVE: To investigate the role of clinical profile and laboratory findings in patients with CSFP. METHODS: We prospectively recruited 69 patients with angiographically diagnosed CSFP and compared them with 88 patients with normal coronary flow. Demographic information, comorbidities and laboratory analysis, including complete blood count with differential, lipid profile and serum biochemical analysis, were documented and compared in univariate and multivariate analyses. RESULTS: Patients with CSFP were more likely to be male and active smokers. Total cholesterol, triglyceride, hemoglobin and hematocrit, platelet count, mean platelet volume, platelet distribution width and red cell distribution width (RDW) were all higher in patients with CSFP. In multivariate regression analysis, including smoking, total cholesterol, hematocrit, fasting blood glucose and red cell distribution width, except fasting blood glucose, all variables were independently associated with CSFP. Receiver operating characteristic curve analysis revealed a cut-off point of 13.05% for RDW with a sensitivity of 74.6% and a specificity of 77.3% (p<0.001, AUC = 0.802) A cut-off value of 11.35% for PDW had a 89.9% sensitivity and 98.9% specificity for the prediction of CSFP (p<0.001, AUC = 0.970) Conclusion: The changes of circulating blood cell components in patients with CSFP may be indicative of underlying inflammation and endothelial dysfunction that should be investigated in experimental studies.

The incidence of slow flow after rotational atherectomy of calcified coronary arteries: A randomized study of low speed versus high speed.

OBJECTIVES: The purpose of this randomized trial was to compare the incidence of slow flow between low-speed and high-speed rotational atherectomy (RA) of calcified coronary lesions. BACKGROUND: Preclinical studies suggest that slow flow is less frequently observed with low-speed than high-speed RA because of less platelet aggregation with low-speed RA. METHODS: This was a prospective, randomized, single center study. A total of 100 patients with calcified coronary lesions were enrolled and randomly assigned in a 1:1 ratio to low-speed (140,000 rpm) or high-speed (190,000 rpm) RA. The primary endpoint was the occurrence of slow flow following RA. Slow flow was defined as slow or absent distal runoff (Thrombolysis in Myocardial Infarction [TIMI] flow grade ≤ 2). RESULTS: The incidence of slow flow in the low-speed group (24%) was the same as that in the high-speed group (24%) (P = 1.00; odds ratio, 1.00; 95% confidence interval, 0.40-2.50). The frequencies of TIMI 3, TIMI 2, TIMI 1, and TIMI 0 flow grades were similar between the low-speed (TIMI 3, 76%; TIMI 2, 14%; TIMI 1, 8%; TIMI 0, 2%) and high-speed (TIMI 3, 76%; TIMI 2, 14%; TIMI 1, 10%; TIMI 0, 0%) groups (P = 0.77 for trend). The incidence of periprocedural myocardial infarction was the same between the low-speed (6%) and high-speed (6%) groups (P = 1.00). CONCLUSIONS: This randomized trial did not show a reduction in the incidence of slow flow following low-speed RA as compared with high-speed RA (UMIN ID: UMIN000015702). © 2016 Wiley Periodicals, Inc.

In-Lab Upfront Use of Tirofiban May Reduce the Occurrence of No-Reflow During Primary Percutaneous Coronary Intervention. A Pilot Randomized Study / Uso de Tirofibana em Laboratório pode Reduzir Ocorrência de não Reperfusão Durante Intervenção Coronariana Percutânea Primária. Um Estudo Piloto Randomizado

Abstract Background: Despite successful opening of culprit coronary artery, myocardial reperfusion does not always follows primary percutaneous coronary intervention (PPCI). Glycoprotein IIb/IIIa inhibitors are used in the treatment of no-reflow (NR), but their role to prevent it is unproven. Objective: To evaluate the effect of in-lab administration of tirofiban on the incidence of NR in ST-elevation myocardial infarction (STEMI) treated with PPCI. Methods: STEMI patients treated with PPCI were randomized (24 tirofiban and 34 placebo) in this double-blinded study to assess the impact of intravenous tirofiban on the incidence of NR after PPCI according to angiographic and electrocardiographic methods. End-points of the study were: TIMI-epicardial flow grade; myocardial blush grade (MBG); resolution of ST-elevation < 70% (RST < 70%) at 90min and 24h after PPCI. Results: Baseline anthropometric, clinical and angiographic characteristics were balanced between the groups. The occurrence of TIMI flow < 3 was not significantly different between the tirofiban (25%) and placebo (35.3%) groups. MBG ≤ 2 did not occur in the tirofiban group, and was seen in 11.7% of patients in the placebo group (p=0.13). RST < 70% occurred in 41.6% x 55.8% (p=0.42) at 90min and in 29% x 55.9% (p=0.06) at 24h in tirofiban and placebo groups, respectively. Severe NR (RST ≤ 30%) was detected in 0% x 26.5% (p=0.01) at 90 min, and in 4.2% x 23.5% (p=0.06) at 24h in tirofiban and placebo groups, respectively. Conclusion: This pilot study showed a trend toward reduction of NR associated with in-lab upfront use of tirofiban in STEMI patients treated with PPCI and paves the way for a full-scale study testing this hypothesis.

Resumo Fundamento: Mesmo com abertura da artéria coronária culpada bem sucedida, a reperfusão miocárdica nem sempre sucede a intervenção coronariana percutânea primária (ICPP). Inibidores da glicoproteína IIb/IIIa são usados no tratamento do fenômeno de não reperfusão (NR), mas seu papel para preveni-lo não está comprovado. Objetivo: Avaliar o efeito da administração, em laboratório, de tirofibana sobre a incidência de NR em infarto agudo do miocárdio com supra do segmento ST (IAMCSST) tratado com ICPP. Métodos: Pacientes com IAMCSST tratados com ICPP foram randomizados (24 tirofibana e 34 placebo) neste estudo duplo-cego para avaliar o impacto de tirofibana intravenosa sobre a incidência de NR após ICPP de acordo com métodos angiográficos e eletrocardiográfico. Os desfechos do estudo foram: fluxo epicárdico TIMI (grau), grau de fluxo miocárdico (MBG), resolução da elevação do segmento ST < 70% (RST < 70%) aos 90 minutos e 24 horas após ICPP. Resultados: Características antropométricas, clínicas e angiográficas basais eram equilibradas entre os grupos. A ocorrência de fluxo TIMI < 3 não foi significativamente diferente entre os grupos tirofibana (25%) e placebo (35,3%). MBG ≤ 2 não ocorreu no grupo tirofibana, e foi detectado em 11,7% dos pacientes do grupo placebo (p=0,13). RST < 70% ocorreu em 41,6% x 55,8% (p=0.42) aos 90 minutos, e em 29% x 55,9% (p=0,06) em 24 horas nos grupos tirofibana e placebo, respectivamente. NR grave (RST ≤ 30%) ocorreu em 0% x 26,5% (p=0,01) aos 90 minutos, e em 4,2% x 23,5% (p=0,06) em 24 horas nos grupos tirofibana e placebo, respectivamente. Conclusão: Este estudo piloto mostrou uma tendência de redução de NR associada ao uso, em laboratório, de tirofibana em pacientes com IAMCSST tratados com ICPP, e abre caminho para um estudo em escala real que teste essa hipótese.

[A high-volume single center experience of no-reflow post-percutaneous coronary intervention]. / Incidenza del no-reflow calcolata su oltre 19 000 angioplastiche primarie ed elettive in un singolo centro ad alto volume.

BACKGROUND: The no-reflow (NR) phenomenon is frequent in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). However, its real incidence and prognostic significance, so far derived from relatively small patient cohorts, remain poorly defined. METHODS: We have retrospectively analyzed 19 290 consecutive PCI performed at our hospital between January 1998 and November 2010. NR was defined as a TIMI flow ≤2 at the end of the PCI. RESULTS: In the 1257 patients with STEMI, NR occurred in 9.4% of cases and was more common when the left anterior descending coronary artery was the culprit vessel. STEMI-NR patients had longer ischemic times and more frequently multivessel disease. In the STEMI-NR group, glycoprotein IIb/IIIa inhibitors were used in 60.2%, nitroprusside in 39.6%, thrombus aspiration in 10.7% and adenosine in 8.7%. In the remaining 18033 patients without STEMI undergoing PCI, the NR phenomenon occurred only in 0.2% of cases. STEMI-NR patients had lower left ventricular ejection fraction at discharge (50.3 ± 7.2 vs 44.9 ± 8.4%; p<0.01) and showed higher rates of adverse events (death, non-fatal myocardial infarction, coronary revascularization, new hospital admission for heart failure: 67.8 vs 36.9%, p=0.001), death (25.4 vs 13.2%, p<0.01), myocardial infarction (13.6 vs 4.8%, p<0.01) and hospitalizations for heart failure (13.6 vs 4.8%, p<0.001). CONCLUSIONS: Our data, derived from a large cohort of patients from a single center, allow a more correct estimate of the occurrence and prognostic significance of NR. The NR phenomenon is more common in STEMI patients undergoing primary PCI and has an important negative prognostic value.

The relationship between neutrophil/lymphocyte ratio and the TIMI flow grade in patients with STEMI undergoing primary PCI.

OBJECTIVES: ST segment elevation myocardial infarction (STEMI) is an important cause of the morbidity and mortality in coronary artery disease. The aim of this study is to investigate the relationship between hematologic parameters and post primary PCI coronary no-reflow. PATIENTS AND METHODS: A total of 145 consecutive STEMI patients (mean age=58.2±12.3 years) and healthy volunteer admitted within 6 hours from symptom onset were enrolled to the study in the cardiology clinics. The STEMI patients were divided into 2 groups based on the Thrombolysis In Myocardial Infarction (TIMI) flow grade. No-reflow was defined as post-PCI TIMI Flow Grade 0, 1 or 2 and angiographic success was defined as TIMI Grade 3 Flow. RESULTS: Diabetes mellitus hypertension and smoking status were similar between groups. With respect to baseline laboratory status, fasting glucose, blood urea nitrogen, creatinine levels were not significantly different between groups. The neutrophil/lymphocyte (N/L) ratio was also significantly higher in STEMI group (7.1±4.6 vs. 2.3±1.7, p < 0.001). Additionally, N/L ratio was also significantly higher in No-reflow group (TIMI Flow Grade 0, 1 or 2) group (13.1±4.5 vs. 5.3±2.7, p < 0.001). CONCLUSIONS: The N/L ratio, which is cheaply and easily measurable laboratory data is independently associated with post primary PCI coronary no-reflow.

Increased serum resistin levels in patients with coronary slow-flow phenomenon.

BACKGROUND: Slow coronary flow (SCF) is an angiographic finding characterized by delayed opacification of the epicardial coronary arteries without obstructive coronary disease. Resistin, an adipocytokine, plays a major role besides low-grade inflammation in atherosclerotic vascular processes and may be of importance in other coronary pathologies such as SCF. METHODS: The present study was cross-sectional and observational, consisting of 70 individuals who underwent coronary angiography and had angiographically normal coronary arteries of varying coronary flow rates. The study included 50 patients with isolated SCF and 20 control participants with normal coronary flow (NCF). RESULTS: There were no statistically significant differences between the SCF and NCF groups with respect to age, gender, presence of hypertension or diabetes mellitus, and smoking habit, except for increased creatinine levels (p = 0.014). The serum resistin level was significantly higher in the SCF group than in the NCF group (8.4 ± 7.2 vs. 5.4 ± 2.6 ng/ml, p = 0.014). Ln-transformed resistin levels correlated positively with left anterior descending (LAD) coronary artery TIMI frame count (TFC) (r = 0.408, p < 0.001) as well as with glucose (r = 0.340, p = 0.004), creatinine (r = 0.248, p = 0.044), and C-reactive protein (CRP; r = 0.283, p = 0.023) levels, and negatively with LAD coronary flow velocity (r = - 0.314, p = 0.009). When multivariate analyses were performed, in linear regression analysis, ln-resistin was associated with a longer TFC [beta (standardized regression coefficient): 0.404, p = 0.001] and lower coronary flow velocity (beta: - 0.280, p = 0.035); in logistic regression analysis, ln-resistin was an independent predictor of the presence of SCF (OR: 6.692, 65 %CI: 1.117-40.1, p = 0.037). CONCLUSION: We demonstrated, for the first time, a significant increase in serum resistin levels in patients with SCF compared to subjects with NCF. We believe that further studies are needed to clarify the role of resistin in patients with SCF.

Beta-blocker use is not associated with slow flow during rotational atherectomy.

OBJECTIVES: The purpose of this study was to investigate the association between beta-blocker use and slow flow during rotational atherectomy (RA). BACKGROUND: RA is often performed as part of percutaneous coronary interventions for the treatment of calcified lesions; however, the procedure can be complicated by slow flow. Previous reports suggested that the use of beta-blockers was associated with slow flow during RA. METHODS: A total of 186 patients who received RA were included, and 87 patients were on beta-blockers. The occurrence of slow flow was compared between the beta-blocker group (n = 87) and the non-beta-blocker group (n = 99). Multivariate logistic regression analysis was performed to investigate whether the use of beta-blockers was associated with slow flow. RESULTS: The occurrence of slow flow was not different between the beta-blocker group (29.9%) and the non-beta-blocker group (24.2%; P=.39). The use of beta-blockers was not significantly associated with slow flow (odds ratio, 0.75; 95% confidence interval, 0.34-1.68; P=.49) after controlling for all potential confounding factors. CONCLUSIONS: There was no definitive association between slow flow and the use of beta-blockers during RA. There is no need to discontinue beta-blockers in patients receiving RA.

Failed percutaneous coronary intervention: a decade of experience in 21,000 patients.

OBJECTIVES: The purpose of this study was to evaluate the incidence, mechanisms, and in-hospital outcomes after failed percutaneous coronary intervention (PCI). BACKGROUND: The most common causes of PCI failure are severe dissection, no-reflow, and uncrossable total occlusions. METHODS: Demographic, clinical, procedural, and quality assurance data were recorded in a prospective database to determine the incidence and outcome of failed PCI. Data were analyzed according to the year of PCI: prestent era (PSE 1993-1995), first generation stent era (FGSE 1996-2000), and contemporary stent era (CSE 2000-2003). RESULTS: PCI (20,884) were performed over a 10-year-period from 1993 through 2003, including 4,344 (20.8%) in the PSE, 9,114 (43.6%) in the FGSE, and 7,426 (35.6%) in the CSE; 19,171 (91.8%) were successful and 1,704 (8.2%) were failures. Nearly 90% of PCI failures are due to no-reflow or uncrossable total occlusions. Among PCI failures, 7.5% were treated medically and 0.7% required emergency coronary artery bypass grafting (ECABG). PCI success was independently associated with PCI during CSE (OR 1.86, P < 0.0001). ECABG decreased sixfold from 1.2% in the PSE to 0.2% in the CSE. CONCLUSIONS: Contemporary PCI patients have better procedural outcomes and fewer in-hospital adverse events than patient treated before the availability of stents. However, recanalization of total occlusions and avoiding no-reflow will have the most impact on future PCI success.