«No-reflow» phenomenon: clinical aspects of reperfusion failure

Abstract

«No-reflow» phenomenon is the most striking example of myocardial reperfusion clinical failure. It is caused by a lack of adequate blood flow in tissues after successful recanalization of infarct-related artery and is of multifactorial nature. The main reason for «no-reflow» is microvascular damage, of both structural and functional nature. Microvascular microemboli formation is also of particular importance in developing this phenomenon. In patients with acute coronary syndrome undergoing thrombolysis, percutaneous coronary intervention or coronary artery bypass surgery, the risk for «no-reflow» is about 30% or more. In case of planned endovascular interventions, «no-reflow» prevalence ranges from 0.3 to 2%. Patients with «no-reflow» have highly increased risk of complications such as reduced systolic function, heart muscle remodeling, dilatation, cardiac chambers hypertrophy/hyperplasia, left ventricular aneurysm etc. In addition, «no-reflow» increases the risk of death. Predisposition for «no-reflow» might be associated with a number of local and systemic factors. For diagnosing this phenomenon, angiographic grading of coronary blood flow restoration (Thrombolysis in Myocardial Infarction - TIMI) and myocardial perfusion (Myocardial Blush Grade - MBG) is recommended. For the most accurate «no-reflow» diagnosis, different methods for myocardium visualization might be used. The most studied treatments of ongoing «no-reflow» are: vasodilators administered intracoronary (verapamil, adenosine, sodium nitroprusside) at percutaneous coronary intervention or coronary artery bypass surgery; systemic antiplatelet agents; mechanical protection from distal embolization. Given the multifactorial nature of the «no-reflow», further search for the novel methods for prevention and treatment of this phenomenon is needed.

Keywords

acute coronary syndrome / infarct-related artery / percutaneous coronary intervention / myocardial reperfusion / «no-reflow» phenomenon

References

[1] Голощапов-Аксёнов Р.С., Терновых М.В., Лебедев А.В. и др. Применение фильтра-проводника для профилактики феномена «no-reflow» при эндоваскулярной реваскуляризации коронарных артерий у больного острым инфарктом миокарда // Диагност. и интервенц. радиол. - 2012. - Т. 6, №3-1. - С. 73-80.

[2] Коваль М. Феномен «no-reflow» - ложка дёгтя в бочке меда реваскуляризации // Med. Review. - 2008. - №5 (05). - С. 32-36.

[3] Крыжановская С.А., Матюшин Г.В., Протопопов А.В. Феномен «no-reflow»: факторы, определяющие риск развития и особенности ЭКГ-изменений // Функционал. диагн. - 2011. - №3. - С. 82.

[4] Пархоменко А.Н. Феномен невосстановленного кровотока у больных с острым коронарным синдромом и возможные пути улучшения тканевой перфузии // Украин. кардиол. ж. - 2007. - №5. - С. 17-25.

[5] Певзнер Д.В., Староверов И.И., Самко А.Н., Мазуров А.В. и др. Применение антагониста гликопротеинов IIb-IIIа монафрама при первичной ангиопластике у больных с острым коронарным синдромом без подьёма сегмента ST // Кардиология. - 2010. - Т. 50, №6. - С. 22-26.

[6] Сидоренко Г.И., Островский Ю.П. Феномен «невозобновления кровотока» (no-reflow) и его клиническое значение // Кардиология. - 2002. - Т. 42, №5. - С. 74-80.

[7] Anderson J.L., Adams C.D., Antman E.M. et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non_ST_elevation myocardial infarction - executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) // J. Am. Coll. Cardiol. - 2007. - Vol. 50. - P. 652-726. http://dx.doi.org/10.1016/j.jacc.2007.02.028

[8] De Lemos J.A., Antman E.M., Giugliano R.P. ST-segment resolution and infarct-related artery patency and flow after thrombolytic therapy: Thrombolysis in Myocardial Infarction (TIMI) 14 investigators // Am. J. Cardiol. - 2000. - Vol. 85. - P. 299-304. http://dx.doi.org/10.1016/S0002-9149(99)00736-5

[9] Eeckhout E., Kern M.J. The coronary no-reflow phenomenon: a review of mechanisms and therapies // Eur. Heart J. - 2001. - Vol. 22. - P. 729-739. http://dx.doi.org/10.1053/euhj.2000.2172

[10] Elbarouni B., Goodman S.G., Yan R.T. et al. Validation of the Global Registry of Acute Coronary Event (GRACE) risk score for in-hospital mortality in patients with acute coronary syndrome in Canada // Am. Heart. J. - 2009. - Vol. 158. - P. 392-399. http://dx.doi.org/10.1016/j.ahj.2009.06.010

[11] Fischell T.A. Pharmaceutical interventions for the management of no-reflow // J. Invasive Cardiol. - 2008. - Vol. 20, N 7. - Р. 374-379.

[12] Giampaolo N., Buzzotta F., Gialuto L., Crea F. Myocardial no-reflow in humans // JACC. - 2009. - Vol. 54, N 4. - P. 281-292. http://dx.doi.org/10.1016/j.jacc.2009.03.054

[13] Henriques J., Zijlstra F., Ottervanger J. et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction // Eur. Heart J. - 2002. - Vol. 23. - P. 1112-1117. http://dx.doi.org/10.1053/euhj.2001.3035

[14] Herrmann J., Lerman A., Baumgart D. et al. Preprocedural statin medication reduces the extent of periprocedural non-Q-wave myocardial infarction // Circulation. - 2002. - Vol. 106. - P. 2180-2183. http://dx.doi.org/10.1161/01.CIR.0000037520.89770.5E

[15] Ito H. No-reflow phenomenon and prognosis in patients with acute myocardial infarction // Nat. Clin. Pract. Cardiovasc. Med. - 2006. - Vol. 3. - P. 499-506. http://dx.doi.org/10.1038/ncpcardio0632

[16] Kaul S., Ito H. Microvasculature in acute myocardial ischemia // Circulation. - 2004. - Vol. 109. - P. 146-149. http://dx.doi.org/10.1161/01.CIR.0000111582.02736.CD

[17] Lee K.W., Norell M.S. Management of «no-reflow» complicating reperfusion therapy // Acute Card. Care. - 2008. - Vol. 10, N 1. - Р. 5-14.

[18] Ndrepepa G., Tiroch K., Fusaro M. et al. Five-year prognostic value of no-reflow phenomenon after percutaneous coronary intervention in patients with acute myocardial infarction // J. Am. Coll. Cardiol. - 2010. - Vol. 55. - P. 2383-2389. http://dx.doi.org/10.1016/j.jacc.2009.12.054

[19] Paul A. Grabern, Choi J.W. Advances in the assessment of no-reflow after successful primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction // JACC. - 2008. - Vol. 51, N 5. - P. 566-568. http://dx.doi.org/10.1016/j.jacc.2007.10.024

[20] Porto I., Ashar V., Mitchell A.R. Pharmacological management of no reflow during percutaneous coronary intervention // Curr. Vasc. Pharmacol. - 2006. - Vol. 4, N 2. - P. 95-100. http://dx.doi.org/10.2174/157016106776359835

[21] Rezkalla S.H., Kloner R.A. Coronary no-reflow phenomenon: from the experimental laboratory to the cardiac catheterization laboratory // Catheter Cardiovasc. Interv. - 2008. - Vol. 72, N 7. - P. 950-957. http://dx.doi.org/10.1002/ccd.21715

[22] Theilmeier G., Verhamme P., Dymarkowski M. et al. Hypercholesterolemia in minipigs impairs left ventricular response to stress: association with decreased coronary flow reserve and reduced capillary density // Circulation. - 2002. - Vol. 106. - P. 1140-1146. http://dx.doi.org/10.1161/01.CIR.0000026805.41747.54

[23] Valero S.J., Moreno R., Reyes R.M. et al. Pharmacological approach of no-reflow phenomenon related with percutaneous coronary interventions // Cardiovasc. Hematol. Agents Med. Chem. - 2008. - Vol. 6, N 2. - Р. 125-129.

[24] Van de Werf F., Bax J., Betriu A. et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology // Eur. Heart J. - 2008. - Vol. 29. - Р. 2909-2945.

[25] Van Gaal W.J., Banning A.P. Percutaneous coronary intervention and the no-reflow phenomenon // Expert Rev. Cardiovasc. Ther. - 2007. - Vol. 5, N 4. - P. 715-731. http://dx.doi.org/10.1586/14779072.5.4.715

RIGHTS & PERMISSIONS

Iskhakov M.M., Tagirova D.R., Gazizov N.V., Nugaybekova L.A., Sayfutdinov R.G.