Clinical, Laboratory, and Procedural Predictors of No-Reflow in Patients Undergoing Primary Percutaneous Coronary Intervention
Background: No-reflow is a major challenging issue in the management of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). This study aimed to investigate the clinical, laboratory, and procedural predictors of no-reflow.
Methods: This study was conducted on 378 patients with STEMI admitted to Dr. Heshmat Educational and Remedial Center (a referral heart hospital in Rasht, Iran) between 2015 and 2017. The study population was divided based on the thrombolysis in myocardial infarction (TIMI) flow grade and the myocardial blush grade into no-reflow and reflow groups. The clinical, laboratory, and procedural characteristics at admission were compared between the 2 groups using the multivariate logistic regression analysis.
Results: The mean age of the participants was 58.57±11.49 years, and men comprised 74.1% of the study population. The no-reflow phenomenon was found in 77 patients. The no-reflow group was significantly older and more likely to be female; additionally, it had higher frequencies of hypertension, diabetes mellitus, hyperlipidemia, and a history of cardiovascular diseases. The multivariate logistic regression analysis showed that age >60 years (OR=1.05, 95% CI:1.00–1.09), hypertension (OR=2.91, 95% CI:1.35–6.27), diabetes (OR=4.18, 95% CI:1.89–9.22), a low systolic blood pressure (OR=3.53, 95% CI:1.02–12.2), a history of cardiovascular diseases (OR=4.29, 95% CI:1.88–9.77), chronic heart failure (OR=4.96, 95% CI:1.23–20), a low initial TIMI flow grade (OR=7.58, 95% CI:1.46–39.2 ), anemia (OR=3.42, 95% CI:1.33–8.77), and stenting vs. balloon angioplasty (OR=0.42, 95% CI:0.19–0.91) were the significant independent predictors of no-reflow.
Conclusion: This study revealed some clinical, laboratory, and procedural predictors of no-reflow for the prediction of high-risk patients and their appropriate management to reduce the risk of no-reflow.
2. Gupta S, Gupta M. No reflow phenomenon in percutaneous coronary interventions in ST-segment elevation myocardial infarction. Indian Heart Journal 2016;68:539-551.
3. Durante A, Camici PG. Novel insights into an "old" phenomenon: the no reflow. Int J Cardiol 2015;187:273-280.
4. Kurtul A, Yarlioglues M, Murat SN, Ergun G, Duran M, Kasapkara HA, Demircelik MB, Cetin M, Ocek AH. Usefulness of the platelet-to-lymphocyte ratio in predicting angiographic reflow after primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction. Am J Cardiol 2014;114:342-347.
5. Stone GW, Peterson MA, Lansky AJ, Dangas G, Mehran R, Leon MB. Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction. J Am Coll Cardiol 2002;39:591-597.
6. Harrison RW, Aggarwal A, Ou FS, Klein LW, Rumsfeld JS, Roe MT, Wang TY. Incidence and outcomes of no-reflow phenomenon during percutaneous coronary intervention among patients with acute myocardial infarction. Am J Cardiol 2013;111:178-184.
7. Rezkalla SH, Kloner R. No-reflow phenomenon. Circulation 2002;105:656-662.
8. Rezkalla SH, Kloner RA. Coronary no-reflow phenomenon: from the experimental laboratory to the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2008;72:950-957.
9. Henriques JP, Zijlstra F, van 't Hof AW, de Boer MJ, Dambrink JH, Gosselink M, Hoorntje JC, Suryapranata H. Angiographic assessment of reperfusion in acute myocardial infarction by myocardial blush grade. Circulation 2003;107:2115-2119.
10. Niccoli G, Burzotta F, Galiuto L, Crea F. Myocardial no-reflow in humans. J Am Coll Cardiol 2009;54:281-292.
11. Gibson CM, Cannon CP, Murphy SA, Ryan KA, Mesley R, Marble SJ, McCabe CH, Van De Werf F, Braunwald E. Relationship of TIMI myocardial perfusion grade to mortality after administration of thrombolytic drugs. Circulation 2000;101:125-130.
12. Ito H, Okamura A, Iwakura K, Masuyama T, Hori M, Takiuchi S, Negoro S, Nakatsuchi Y, Taniyama Y, Higashino Y, Fujii K, Minamino T. Myocardial perfusion patterns related to thrombolysis in myocardial infarction perfusion grades after coronary angioplasty in patients with acute anterior wall myocardial infarction. Circulation 1996;93:1993-1999.
13. Kirma C, Izgi A, Dundar C, Tanalp AC, Oduncu V, Aung SM, Sonmez K, Mutlu B, Ozdemir N, Erentug V. Clinical and procedural predictors of no-reflow phenomenon after primary percutaneous coronary interventions: experience at a single center. Circ J 2008;72:716-721.
14. Reffelmann T, Kloner RA. The "no-reflow" phenomenon: basic science and clinical correlates. Heart 2002;87:162-168.
15. Ashraf T, Khan MN, Afaque SM, Aamir KF, Kumar M, Saghir T, Rasool SI, Rizvi SNH, Sial JA, Nadeem A, Khan AA, Karim M. Clinical and procedural predictors and short-term survival of the patients with no reflow phenomenon after primary percutaneous coronary intervention. Int J Cardiol 2019;294:27-31.
16. Chesebro JH, Knatterud G, Roberts R, Borer J, Cohen LS, Dalen J, Dodge HT, Francis CK, Hillis D, Ludbrook P. Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: a comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation 1987;76:142-154.
17. Alidoosti M, Lotfi R, Lotfi-Tokaldany M, Nematipour E, Salarifar M, Poorhosseini H, Jalali A. Correlates of the "no-reflow" or "slow-flow" phenomenon in patients undergoing primary percutaneous coronary intervention. J Teh Univ Heart Ctr 2018;13:108-114.
18. Fajar JK, Heriansyah T, Rohman MS. The predictors of no reflow phenomenon after percutaneous coronary intervention in patients with ST elevation myocardial infarction: A meta-analysis. Indian Heart J 2018;70 Suppl 3:S406-S418.
19. Mazhar J, Mashicharan M, Farshid A. Predictors and outcome of no-reflow post primary percutaneous coronary intervention for ST elevation myocardial infarction. Int J Cardiol Heart Vasc 2015;10:8-12.
20. Zhou H, He XY, Zhuang SW, Wang J, Lai Y, Qi WG, Yao YA, Liu XB. Clinical and procedural predictors of no-reflow in patients with acute myocardial infarction after primary percutaneous coronary intervention. World J Emerg Med 2014;5:96-102.
21. Ipek G, Onuk T, Karatas MB, Gungor B, Osken A, Keskin M, Oz A, Tanik O, Hayiroglu MI, Yaka HY, Ozturk R, Bolca O. CHA2DS2-VASc score is a predictor of no-reflow in patients with st-segment elevation myocardial infarction who underwent primary percutaneous intervention. Angiology 2016;67:840-845.
22. Mirbolouk F, Gholipour M, Salari A, Shakiba M, Kheyrkhah J, Nikseresht V, Sotoudeh N, Moghadam N, Mirbolouk MJ, Moayeri Far M. CHA2DS2-VASc score predict no-reflow phenomenon in primary percutaneous coronary intervention in primary percutaneous coronary intervention. J Cardiovasc Thorac Res 2018;10:46-52.
23. Hashemi-Jazi M, Hosseini SM, Gholamrezaei A. Factors associated with the no-reflow phenomenon following percutaneous intervention of saphenous vein coronary bypass grafts. ARYA Atheroscler 2017;13:221-229.
24. Galderisi M, de Simone G, Cicala S, Parisi M, D'Errico A, Innelli P, de Divitiis M, Mondillo S, de Divitiis O. Coronary flow reserve in hypertensive patients with hypercholesterolemia and without coronary heart disease. Am J Hypertens 2007;20:177-183.
25. Kozàkovà M, Palombo C, Pratali L, Pittella G, Galetta F, L'Abbate A. Mechanisms of coronary flow reserve impairment in human hypertension. An integrated approach by transthoracic and transesophageal echocardiography. Hypertension 1997;29:551-559.
26. Kozàkovà M, Ferrannini E, Palombo C. Relation between left ventricular midwall function and coronary vasodilator capacity in arterial hypertension. Hypertension 2003;42:528-533.
27. Chen Y, Wang C, Yang X, Wang L, Sun Z, Liu H, Chen L. Independent no-reflow predictors in female patients with ST-elevation acute myocardial infarction treated with primary percutaneous coronary intervention. Heart Vessels 2012;27:243-249.
28. Ishikura F, Miki A, Iwata A, Toshida T, Shakudo M, Asanuma T, Kitakaze M, Shinozaki Y, Mori H, Beppu S. Effect of systemic blood pressure on microcollateral circulation evaluated by real-time contrast echocardiography. J Am Soc Echocardiogr 2008;21:765-769.
29. Varat MA, Adolph RJ, Fowler NO. Cardiovascular effects of anemia. Am Heart J 1972;83:415-426.
30. Marcus ML, White CW. Coronary flow reserve in patients with normal coronary angiograms. J Am Coll Cardiol 1985;6:1254-1256.
31. Dogan NB, Ozpelit E, Akdeniz S, Bilgin M, Baris N. Simple clinical risk score for no-reflow prediction in patients undergoing primary percutaneous coronary intervention with acute STEMI. Pak J Med Sci 2015;31:576-581.
32. Iwakura K, Ito H, Ikushima M, Kawano S, Okamura A, Asano K, Kuroda T, Tanaka K, Masuyama T, Hori M, Fujii K. Association between hyperglycemia and the no-reflow phenomenon in patients with acute myocardial infarction. J Am Coll Cardiol 2003;41:1-7.
33. Zhao JL, Yang YJ, Pei WD, Sun YH, Chen JL. The effect of statins on the no-reflow phenomenon: an observational study in patients with hyperglycemia before primary angioplasty. Am J Cardiovasc Drugs 2009;9:81-89.
34. Malmberg K, Rydén L, Efendic S, Herlitz J, Nicol P, Waldenström A, Wedel H, Welin L. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol 1995;26:57-65.
35. Zhao JL, Fan CM, Yang YJ, You SJ, Gao X, Zhou Q, Pei WD. Chronic pretreatment of metformin is associated with the reduction of the no-reflow phenomenon in patients with diabetes mellitus after primary angioplasty for acute myocardial infarction. Cardiovasc Ther 2013;31:60-64.
36. Bahrehmand M, Sadeghi E, Shafiee A, Nozari Y. Predictors of delayed and no-reflow as recognized with thrombolysis in myocardial infarction [TIMI] flow grade following primary percutaneous coronary angioplasty. J Med Life 2015;8(Spec Iss 3):59-65.
37. De Maria GL, Alkhalil M, Oikonomou EK, Wolfrum M, Choudhury RP, Banning AP. Role of deferred stenting in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention: a systematic review and meta-analysis. J Interv Cardiol 2017;30:264-273.
38. Mahmoud AH, Taha NM, Baraka K, Ashraf M, Shehata S. Clinical and procedural predictors of suboptimal myocardial reperfusion in primary percutaneous coronary intervention. Int J Cardiol Heart Vasc 2019;23:100357.
39. Kurtul A, Ocek AH, Murat SN, Yarlioglues M, Demircelik MB, Duran M, Ergun G, Cay S. Serum albumin levels on admission are associated with angiographic no-reflow after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. Angiology 2015;66:278-285.
40. Abdi S, Rafizadeh O, Peighambari M, Basiri H, Bakhshandeh H. Evaluation of the clinical and procedural predictive factors of no-reflow phenomenon following primary percutaneous coronary intervention. Res Cardiovasc Med 2015;4:e25414.
41. Sensoy B, Uzunget SB, Acikgoz S, Sensoy N, Sen F, Acar B, Canpolat U, Ozeke O, Cay S, Maden O. Renal dysfunction on admission predicts no-reflow phenomenon in patients undergoing manual thrombus aspiration during primary percutaneous coronary intervention. Acta Cardiol Sin 2016;32:185-193.
42. Kurtul A, Murat SN, Yarlioglues M, Duran M, Celik IE, Kilic A. Mild to moderate renal impairment is associated with no-reflow phenomenon after primary percutaneous coronary intervention in acute myocardial infarction. Angiology 2015;66:644-651.
43. Shemirani H, Tafti FD, Amirpour A. Comparison of no-reflow phenomenon after percutaneous coronary intervention for acute myocardial infarction between smokers and nonsmokers. J Res Med Sci 2014;19:1068-1073.
44. Magro M, Nauta ST, Simsek C, Boersma E, van der Heide E, Regar E, van Domburg RT, Zijlstra F, Serruys PW, van Geuns RJ. Usefulness of the SYNTAX score to predict "no reflow" in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am J Cardiol 2012;109:601-606.
45. Şahin DY, Gür M, Elbasan Z, Kuloğlu O, Şeker T, Kivrak A, Tanboğa İH, Gözübüyük G, Kirim S, Çayli M. SYNTAX score is a predictor of angiographic no-reflow in patients with ST-elevation myocardial infarction treated with a primary percutaneous coronary intervention. Coron Artery Dis 2013;24:148-153.
|Issue||Vol 15 No 2 (2020): J Teh Univ Heart Ctr|
|ST elevation myocardial infarction Percutaneous coronary intervention No-reflow phenomenon|
|Rights and permissions|
|This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.|