Diagnosis and Treatment of Thrombotic Storm During Percutaneous Coronary Intervention
张欣欣, 许祥玉, 郭小梅
华中科技大学同济医学院附属同济医院心血管内科,武汉 430030
ZHANG Xinxin,, XU Xiangyu, GUO Xiaomei,
Department of Cardiovascular-Internal Medicine,Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology,Wuhan 430030,China
During percutaneous coronary intervention, thrombotic storm which is mediated by hypercoagulable state, mechanical distension induced-plaque rupture, platelet activation and adhesion is still the main cause of cardiovascular adverse events. The mortality rate is extremely high if not treated properly. Thrombotic storm can be diagnosed quickly through coronary artery angiography and myocardial blush grades. Once coronary thrombosis occurs, medicine including platelet Ⅱb/Ⅲa receptor antagonist tirofiban or vasodilators can rapidly improve coronary flow and effectively treat it.
Task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology(ESC),STEG P G JAMES S K,et al.ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation[J].Eur Heart J,2012,33(20):2569-2619.
Guidelines summarize and evaluate all available evidence at the time of the writing process on a particular issue, with the aim of assisting physicians in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk enefit ratio of particular diagnostic or therapeutic means. Guidelines are not substitutes but are complements for textbooks and cover the ESC Core Curriculum topics. Guidelines and recommendations should help physicians to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible physician(s). A great number of guidelines have been issued in recent years by the European Society of Cardiology (ESC), as well as by other societies and organizations. Because of their impact on clinical practice, quality criteria for the development of guidelines have been established, in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC guidelines can be found on the ESC web site (http://www.escardio.org/ guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). ESC guidelines represent the official position of the ESC on a given topic and are regularly updated.
HARRISON RW,AGGARWALA,OU FS,et al.Incidence and outcomes of no-reflow phenomenon during percutaneous coronary intervention among patients with acute myocardial infarction[J].Am J Cardiol,2013,111(2):178-184.
Previous studies describing the no-reflow phenomenon in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) were largely confined to single-center studies or small registries. To better characterize the incidence, predictors, and outcomes of the no-reflow phenomenon in a large contemporary population, we analyzed patients with AMI who were undergoing PCI of native coronary artery stenoses in the CathPCI Registry from January 1, 2004 through September 5, 2008 (n = 291,380). The angiographic no-reflow phenomenon was site reported using a standardized definition. No-reflow developed in 2.3% of the patients with AMI (n = 6,553) during PCI. Older age, ST-segment elevation AMI, prolonged interval from symptom onset to admission, and cardiogenic shock were clinical variables independently associated with the development of no-reflow (p <0.001). The angiographic factors independently associated with no-reflow included longer lesion length, higher risk class C lesions, bifurcation lesions, and impaired preprocedure Thrombolysis In Myocardial Infarction flow (p <0.001). No-reflow was associated with greater in-hospital mortality (12.6% vs 3.8%, adjusted odds ratio 2.20, 95% confidence interval 1.97 to 2.47, p <0.001) and unsuccessful lesion outcome (29.7% vs 6.6%, adjusted odds ratio 4.70, 95% confidence interval 4.28 to 5.17, p <0.001) compared to patients without no-reflow. In conclusion, the development of no-reflow, although relatively uncommon during PCI for AMI, is associated with adverse clinical outcomes. Upfront strategies to reduce the incidence of no-reflow could be considered for high-risk patients to improve outcomes. (C) 2013 Elsevier Inc. All rights reserved. (Am J Cardiol 2013;111:178-184)
Despite achievement of optimal epicardial coronary flow in the majority of patients treated for ST-segment elevation myocardial infarction (STEMI) by primary percutaneous coronary intervention (PPCI), myocardial no-reflow is a common phenomenon occurring in 5 to 50% of patients. The no-reflow phenomenon is a predictor of infarct size and an independent predictor of mortality both in the short and long term. Prevention of no-reflow is therefore a crucial step in improving prognosis of patients with STEMI. Several strategies including pharmacological and mechanical ones have been developed to improve microvascular perfusion in the setting of a myocardial infarction. Prevention starts by conservation of the microvascular reserve especially in patients at high risk of acute coronary syndromes such as diabetes patients. Optimal glycaemic control and the use of statins have been shown to reduce no-reflow in this context. Reducing ischaemic time by shortening door to balloon times, administration of intracoronary GP IIb/IIIa antagonists during PPCI and the use of manual aspiration thrombectomy have been shown to result in better myocardial perfusion and improved clinical outcome in major trials. In this review we discuss some of these major trials and studies of other therapeutic options that aim to prevent the no-reflow phenomenon.
ABSTRACT Patients with hypercoagulability may present with a single thrombosis and subsequently develop progressive thromboses at other sites. With inadequate therapy, the thrombotic process may self-perpetuate, leading to multiple thromboses and even death. Six cases are presented demonstrating key features of what may be termed thrombotic storm: (1) an underlying hypercoagulable disorder; (2) a provocation to initiate thrombosis; (3) rapid development of new thromboses; (4) response to prompt use of thrombolytic agent or anticoagulant therapy; and (5) remarkable good long-term prognosis if the cycle of thrombosis is interrupted. Continued activation of coagulation by fresh thrombosis is hypothesized as the cause of the syndrome, which may explain its control by anticoagulants. Whereas these unusual patients' courses most likely represent only an extreme of hypercoagulability and not a new disorder, their characteristic behavior warrants attention.
KITCHENS CS,ERKAND,BRANDAO LR,et al.Thrombotic storm revisited:preliminary diagnostic criteria suggested by the thrombotic storm study group[J].Am J Med,2011,124(4):290-296.
Physicians periodically encounter patients with an extraordinarily accelerated course of hypercoagulability who develop thromboses in multiple organ systems over days to weeks. Such patients may harbor underlying hypercoagulable clinical conditions, but their clinical course sets them apart from most patients with similar risk factors. Underlying triggers of "thrombotic storm" include pregnancy, inflammation, trauma, surgery, and infection. Aggressive anticoagulant therapy may control thrombotic storm, yet thrombotic storm may resume with even brief interruptions of anticoagulant therapy. The authors of this communication formed the Thrombotic Storm Study Group in order to identify clinical characteristics of such patients, thus constructing preliminary criteria to better define, identify, and study the course of patients deemed to have thrombotic storm. The characteristics culled from these 10 patients are: younger age (oldest was 38 years old at time of presentation); at least 2 arterial or venous (or both) thromboembolic events, typically in unusual sites with or without microangiopathy; unexplained recurrence; and frequently proceeded by a trigger. The following characteristics were not used in defining thrombotic storm: underlying malignancies; use of acute myocardial infarction as a defining arterial event in the setting of established coronary artery disease; use of cocaine; thrombotic complications expected with various intravascular devices; known paroxysmal nocturnal hemoglobinuria or myeloproliferative disorders; severe trauma; and premorbid conditions. (C) 2011 Elsevier Inc. All rights reserved. The American Journal of Medicine (2011) 124, 290- 296
ARYAL MR,BADALM,BHANDARIN,et al.Accelerated arterial and venous clots in a young pregnant woman:a saga of thrombotic storm[J]. BMJ Case Rep,2013.
ABSTRACT Thrombotic storm is a rare condition, characterised by serial thrombotic events, which escalates rapidly within a few days to a few weeks involving multiple and unusual sites. Since it usually responds to anticoagulation and is often lethal if not treated promptly, early diagnosis is crucial. We describe a case of a young pregnant woman with multiple acute arterial and venous thrombotic events including stroke and myocardial infarction, who successfully recovered with continued anticoagulation therapy.
JEREMI CK,STEFANOVICA,LJUBICA,et al.Multiorgan thrombotic disorder in a young patient with primary antiphospholipid syndrome (APS) and ovarian tumor[J].Eur J Gynaecol Oncol,2013,34(3):273-274.
Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening condition with high mortality rate besides aggressive multimodal treatment. Underlying triggers of "thrombotic and cytokine storm" include pregnancy, inflammation, trauma, surgery, and infection. The authors present a case of a young female patient with primary antiphospholipid syndrome (APS) who was admitted to the hospital due to abdominal pain caused by ovarian tumor with elevated tumor markers. After the prophylactic anticoagulants and antibiotic treatment, surgery was performed. Suddenly after treatment, her clinical status deteriorated and she died regardless of intensive immunosupresive and anticoagulant therapy attempts. This condition requires all clinical awareness, timely diagnosis, and therapeutical approach, including a better understanding of the pathophysiology that leads to CAPS.
ZHAO JL,FAN CM,YANG YJ,et al.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[J].Cardiovasc Ther,2013,31(1):60-64.
Introduction: Metformin is one of the most commonly prescribed antihyperglycemic agents for the treatment of type 2 diabetes. However, little is known about the effect of metformin on no-reflow in diabetic patients. Aim: In this study, we investigated retrospectively whether chronic pretreatment with metformin was associated with no-reflow in diabetic patients who underwent primary coronary intervention for acute myocardial infarction (AMI). Results: A total of 154 consecutive diabetic patients who underwent primary angioplasty for a first ST-segment elevation myocardial infarction were studied. No-reflow was defined as a final TIMI flow of =2 or final TIMI flow of 3 with a myocardial blush grade of <2. The no-reflow phenomenon was found in 53 of 154 patients. There were no significant differences in clinical characteristics between the patients with and without metformin pretreatment. However, the 65 patients receiving chronic metformin treatment before admission had lower incidence of the no-reflow than those without it (4.2 and 14.6%, P < 0.05). Multivariable logistic regression analysis revealed that absence of metformin pretreatment was a significant predictor of the no-reflow along with high-burden thrombus, ejection fraction on admission and anterior AMI. Conclusion: These results suggested that chronic pretreatment with metformin may be associated with the reduction of the no-reflow phenomenon in patients with diabetes mellitus after primary angioplasty for AMI.
WOO SI,PARK SD,KIM DH,et al.Thrombus aspiration during primary percutaneous coronary intervention for preserving the index of microcirculatory resistance:a randomized study[J].Eurointervention,2014,9(9):1057-1062.
Aims: We aimed to investigate whether thrombus aspiration could preserve the index of microcirculatory resistance (IMR) after primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). Methods and results: Sixty-three patients with STEMI were randomised into two groups: primary PCI after thrombus aspiration (aspiration group, n=33) and primary PCI without thrombus aspiration (non-aspiration group, n=30). IMR was measured using a pressure-temperature sensor-tipped coronary wire. Echocardiography was performed at baseline and at six-month follow-up. No significant differences in baseline ejection fraction (EF, 47.3±8.5% vs. 49.5±7.8%, p=0.281) and baseline wall motion score index (WMSI, 1.45±0.31 vs. 1.37±0.27, p=0.299) were observed between the two groups. However, significant differences in IMR (23.5±10.2 U vs. 34.2±21.7 U, p=0.018), %E2%88%86EF (follow-up EF - baseline EF; 3.33±4.6% vs. 0.73±1.9%, p=0.005), and %E2%88%86WMSI (follow-up WMSI - baseline WMSI; -0.121±0.16 vs. -0.004±0.07, p=0.001) were observed between the two groups. Conclusions: Thrombus aspiration as an adjunctive method to primary PCI for STEMI may preserve microvascular integrity and have beneficial effects on myocardial microcirculation.
NOMOTOK,WATANABEI,OBAT,et al.Safety and efficacy of sirolimus-eluting stent in patients with acute coronary syndrome undergoing emergency procedure[J].Circ J, 2008,72(7):1054-1058.
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AHMEDK,JEONG MH,CHAKRABORTYR,et al.Role of intravascular ultrasound in patients with acute myocardial infarction undergoing percutaneous coronary intervention[J].Am J Cardiol,2011,108(1):8-14.
Stent thrombosis and restenosis remain drawbacks of drug-eluting stents in patients with acute myocardial infarction (AMI). Intravascular ultrasound (IVUS) guidance for stent deployment helps optimize its results in stable patients. The aim of this study was to examine the utility of routine IVUS guidance in patients with AMI undergoing percutaneous coronary intervention (PCI). Employing data from Korea Acute Myocardial Infarction Registry (KAMIR), we analyzed 14,329 patients with AM! from April 2006 through September 2010. Patients with cardiogenic shock and rescue PCI after thrombolysis were excluded. Clinical outcomes of 2,127 patients who underwent IVUS-guided PCI were compared to those of 8,235 patients who did not. Mean age was 63.6 +/- 13.5 years and 72.3% were men. Patients undergoing IVUS-guided PCI were younger, more often men, more hyperlipemic, and had increased body mass index and left ventricular ejection fraction. Number of treated vessels and stents used, stent length, and stent diameter were increased in the IVUS-guided group. Multivessel involvement was less frequent and American College of Cardiology/American Heart Association type C lesion was more frequent in the IVUS-guided group. Drug-eluting stents were more frequently used compared to bare-metal stents in the IVUS group. There was no significant relation of stent thrombosis between the 2 groups. Twelve-month all-cause death was lower in the IVUS group. After multivariate analysis and propensity score adjustment, IVUS guidance was not an independent predictor for 12-month all-cause death (hazard ratio 0.212, 0.026 to 1.73, p = 0.148). In conclusion, this study does not support routine use of IVUS guidance for stent deployment in patients who present with AMI and undergo PCI. (C) 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;108:8-14)
KUBOT,IMANISHIT,KASHIWAGIM,et al.Multiplecoronary lesioninst ability in patients with acute myocardial infarction as determined by optical coherence tomography[J].Am J Cardiol,2010,105(3):318-322.
Autopsy studies have suggested that (AMI) represents a pan-coronary process of vulnerable plaque development. We performed multifocal optical coherence tomographic (OCT) examination to compare coronary lesion instability between AMI and (SAP). A total of 42 patients with AMI (n = 26) or SAP (n = 16) who had multivessel disease and underwent multivessel coronary intervention were enrolled in the present study. The OCT examination was performed not only in the -related/, but also in the noninfarct-related/nontarget lesions. OCT-derived thin-cap fibroatheroma (TCFA) was defined as a lesion with a fibrous cap thickness of <65 microm. In the -related/, plaque rupture (77% vs 7%, p <0.001) and intracoronary (100% vs 0%, p <0.001) were observed more frequently in AMI than in SAP. The fibrous cap thickness (57 + or - 12 vs 180 + or - 65 microm, p <0.001) was significantly thinner in AMI and the frequency of OCT-derived TCFA (85% vs 13%, p <0.001) was significantly greater in AMI than in SAP. In the noninfarct-related/nontarget lesions, the frequency of plaque rupture was not different between the 2 groups. Intracoronary was observed in 8% of AMI, but it was not found in SAP. The fibrous cap thickness (111 + or - 65 vs 181 + or - 70 microm, p = 0.002) was significantly thinner in AMI and the frequency of OCT-derived TCFA (38% vs 6%, p = 0.030) was significantly greater in AMI than in SAP. Multiple OCT-derived TCFAs in both the -related/target and the noninfarct-related/nontarget lesions were observed in 38% of patients with AMI but not in patients with SAP (p = 0.007). In conclusion, the present OCT examination demonstrated multiple lesion instability in the presence of AMI.
VAN'T HOF AW,VALGIMIGLIM.Defining the role of platelet glycoprotein receptor inhibitors in STEMI:focus on tirofiban[J].Drugs,2009,69(1):85-100.
Tirofiban is a small molecule, nonpeptide tyrosine derivative. Although similar to abciximab in that it has a high specificity and affinity for the glycoprotein (GP) IIb/IIIa receptor, tirofiban dissociates from the GP IIb/IIIa receptor more rapidly than abciximab. Additionally, the action of tirofiban is reversed within hours after completion of the infusion, whereas abciximab binds irreversibly resulting in a considerably longer effect. The efficacy of tirofiban in ST-segment elevation myocardial infarction (STEMI) has been demonstrated when administered in patients being managed with primary percutaneous coronary intervention (PCI). These trials primarily studied tirofiban utilizing the high-dose bolus regimen (25 microg/kg bolus followed by a maintenance infusion of 0.15 microg/kg/min for 18-24 hours). The On-TIME (Ongoing Tirofiban in Myocardial Infarction Evaluation) 2 trial assessed early administration of the high-dose bolus regimen of tirofiban either at the referral centre or in the ambulance, in patients being transferred to a primary PCI centre. Early use of tirofiban resulted in both a significant increase in the rate of complete resolution of ST-segment deviation pre- and post-PCI, and improvement in clinical outcomes at 30 days. Moreover, the multi-factorial MULTISTRATEGY (Multicentre Evaluation of Single High-Dose Bolus Tirofiban vs Abciximab With Sirolimus-Eluting Stent or Bare Metal Stent in Acute Myocardial Infarction) trial, which compared the high-dose bolus regimen of tirofiban with standard dose administration of abciximab administered immediately prior to PCI, revealed similar effects on myocardial perfusion, ST-segment elevation recovery and clinical outcomes between the two agents, and confirmed the safety of tirofiban when used in combination with drug-eluting stents in patients with STEMI undergoing primary PCI. These studies showed tirofiban to be a well tolerated and effective GP IIb/IIIa inhibitor. On the basis of the demonstrated bene
XUQ,YINJ,SILY,et al.Efficacy and safety of early versus late glycoprotein Ⅱb/Ⅲa inhibitors for PCI[J].Int J Cardiol,2013,162(3):210-219.
Background: Glycoprotein (Gp) IIb/IIIa inhibitors are beneficial for patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). However, optimal drug timing remains inconclusive. Therefore, this study was to perform a meta-analysis of the clinical efficiency and safety of early versus late GpIIb/IIIa inhibitors in STEMI patients undergoing PCI.<br/>Methods: A comprehensive search was to identify randomized trials of early versus late GpIIb/IIIa inhibitors in STEMI patients undergoing PCI. The GpIIb/IIIa inhibitors were abciximab and small-molecular Gp inhibitors (SMGP) namely eptifibatide and tirofiban. The efficacy endpoints included pre-procedural Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow, post-procedural TIMI 3 flow, complete ST-segment resolution, left ventricle ejection fraction (LVEF), and mortality. The safety endpoint was the occurrence of major bleeding complications.<br/>Results: Nineteen trials were included in the meta-analysis, involving 4209 patients (early 2124 versus late 2085). Early GpIIb/IIIa inhibitors significantly improved pre-procedural TIMI 3 flow, while early abciximab, but not SMGP, further enhanced post-procedural TIMI 3 flow, complete ST-segment resolution, LVEF, and reduced six-month mortality. In addition to clopidogrel loading, only early abciximab improved pre-procedural TIMI 3 flow and complete ST-segment resolution. The rate of major bleeding complications was not increased in early GpIIb/IIIa inhibitors with/without clopidogrel loading.<br/>Conclusions: Early GpIIb/IIIa inhibitors improved pre-procedural TIMI 3 flow and early abciximab provided favorable clinical outcomes in STEMI patients undergoing PCI. On the basis of clopidogrel loading, early abciximab enhanced pre-procedural TIMI 3 flow and ST-segment resolution. These beneficial effects were achieved without increased risks of major bleeding complications. (C) 2012 Elsevier Ireland Ltd. All rights reserved.
AKPEKM,SAHINO,SARLIB,et al.Acute effects of intracoronary tirofiban on no-reflow phenomena in patients with ST-segment elevated myocardial infarction undergoing primary percutaneous coronary intervention[J].Angiology, 2015,66(6):560-567.
Abstract We evaluated the acute effect of intracoronary administration of tirofiban on no-reflow phenomenon in patients with ST-segment elevated myocardial infarction undergoing primary percutaneous coronary intervention. Consecutive patients (n = 162) were randomized into 2 groups based on whether intracoronary tirofiban was administered. After the administration of intracoronary tirofiban, thrombolysis in myocardial infarction (TIMI) flow grade significantly increased (P < .001) and successful reperfusion was achieved in 26 (32%) patients. In the placebo group, however, after the administration of intracoronary placebo the TIMI flow grade did not change (P = .070), and successful reperfusion was achieved only in 8 (10%) patients. In-hospital major adverse cardiac events (MACE) were significantly lower in the tirofiban group (36% vs 19%, P = .013). Intracoronary administration of tirofiban significantly improves TIMI flow grade and is associated with a lower in-hospital rate of MACE.
VAN'T H AW,TEN BJ,HEESTERMANST,et al.Prehospital initiation of tirofiban in patients with ST-elevation myocardial infarction undergoing primary angioplasty (on-TIME 2) :a multicentre,double-blind,randomised controlled trial[J].Lancet,2008,372(9638):537-546.
Abstract BACKGROUND: The most effective magnitude and timing of antiplatelet therapy is important in patients with acute ST-elevation myocardial infarction (STEMI). We investigated whether the results of primary coronary angioplasty (PCI) can be improved by the early administration of the glycoprotein IIb/IIIa blocker tirofiban at first medical contact in the ambulance or referral centre. METHODS: We undertook a double-blind, randomised, placebo-controlled trial in 24 centres in the Netherlands, Germany, and Belgium. Between June 29, 2006, and Nov 13, 2007, 984 patients with STEMI who were candidates to undergo PCI were randomly assigned to either high-bolus dose tirofiban (n=491) or placebo (N=493) in addition to aspirin (500 mg), heparin (5000 IU), and clopidogrel (600 mg). Randomisation was by blinded sealed kits with study drug, in blocks of four. The primary endpoint was the extent of residual ST-segment deviation 1 h after PCI. Analysis was by intention to treat. The trial is registered, number ISRCTN06195297. FINDINGS: 936 (95%) patients were randomly assigned to treatment after a prehospital diagnosis of myocardial infarction in the ambulance. Median time from onset of symptoms to diagnosis was 76 min (IQR 35-150). Mean residual ST deviation before PCI (10.9 mm [SD 9.2] vs 12.1 mm [9.4], p=0.028) and 1 h after PCI (3.6 mm [4.6] vs 4.8 mm [6.3], p=0.003) was significantly lower in patients pretreated with high-bolus dose tirofiban than in those assigned to placebo. The rate of major bleeding did not differ significantly between the two groups (19 [4%] vs 14 [3%]; p=0.36). INTERPRETATION: Our finding that routine prehospital initiation of high-bolus dose tirofiban improved ST-segment resolution and clinical outcome after PCI, emphasises that further platelet aggregation inhibition besides high-dose clopidogrel is mandated in patients with STEMI undergoing PCI.
NICCOLIG,COSENTINON,SPAZIANIC,et al.New strategies for the management of no-reflow after primary percutaneous coronary intervention[J].Expert Rev Cardiovasc Ther,2011,9(5):615-630.
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QINT,XIEL,CHEN MH.Meta-analysis of randomized controlledtrials on the efficacy and safety of intracoronary administration of tirofiban for no-reflow phenomenon[J].BMC Cardiovasc Disord,2013,13:68.
Currently, there is still a lack of an optimal treatment for no-reflow phenomenon (NR). The aim of this simple meta-analysis was to evaluate the efficacy and safety of intracoronary (IC) administration of tirofiban compared with other conventional drugs during percutaneous coronary intervention (PCI) for NR.
ABSTRACT Sodium nitroprusside is one of several agents considered effective for treating the no-reflow phenomenon during acute coronary interventions. However, the coronary hyperemic dose responses and systemic hemodynamic effects of intracoronary nitroprusside have yet to be determined in humans. The purpose of this study was to compare the hyperemic and hemodynamic responses of intracoronary nitroprusside to intracoronary adenosine in patients during cardiac catheterization with angiographically normal anterior descending arteries. In 21 patients, coronary blood flow velocity (0.014-inch Doppler flow wire), heart rate, and blood pressure were measured in unobstructed left anterior descending coronary arteries at rest, after intracoronary adenosine (30- to 50-microg boluses), and after 3 serial doses (0.3-, 0.6-, and 0.9-microg/kg boluses) of intracoronary nitroprusside. Coronary reserve was calculated as hyperemia/basal coronary flow velocity. In an additional 9 patients with intermediate stenoses (53+/-7%), 14 fractional flow reserve (FFR) measurements (using 0.014-inch pressure wire) were performed with both intracoronary adenosine and nitroprusside (0.6 microg/kg). Intracoronary nitroprusside produced equivalent coronary hyperemia with a longer duration ( approximately 25%) compared with intracoronary adenosine. Intracoronary nitroprusside (0.9 microg/kg) decreased systolic blood pressure by <20%, with minimal change in heart rate, whereas intracoronary adenosine had no effect on these parameters. FFR measurements with intracoronary nitroprusside were identical to those obtained with intracoronary adenosine (r=0.97). Compared with adenosine, intracoronary nitroprusside produces an equivalent but more prolonged coronary hyperemic response in normal coronary arteries. Intracoronary nitroprusside, in doses commonly used for the treatment of the no-reflow phenomenon, can produce sustained coronary hyperemia without detrimental systemic hemodynamics. On the basis of FFR measurements compared with adenosine, sodium nitroprusside also appears to be a suitable hyperemic stimulus for coronary physiological measurements.
GALASSOG,SCHIEKOFERS,D’ANNA C,et al.No-reflow phenomenon:pathophysiology,diagnosis,prevention,and treatment.A review of the current literature and future perspectives[J].Angiology,2014,65(3):180-189.
No-reflow is responsible for 40% of the primary percutaneous coronary intervention without complete myocardial reperfusion despite successful reopening of the infarct-related artery. This review...
SHEHATAM.Cardioprotective effects of oral nicorandil use in diabetic patients undergoing elective percutaneous coronary intervention[J].J Interv Cardiol,2014,27(5):472-481.
ABSTRACT Myocardial injury commonly occurs during percutaneous coronary intervention (PCI). Several agents that mimic ischemic preconditioning could help minimize this phenomenon. This study evaluated the cardioprotective role of intracoronary Adenosine in elective PCI. 100 diabetic patients with chronic stable angina were prospectively enrolled, then randomly assigned to undergo PCI with intracoronary Adenosine; 100 μg/stented vessel (group-A,50patients) or standard PCI (group-B,50patients). Cardiac Troponin I (cTnI) & Creatine KinaseMB (CKMB) levels were measured before & 6, 12 and 24 hours postPCI. Mean age of the study cohort was 57 ± 8 years (males=63%). cTnI level was significantly lower in group-A (6 hours: 7.5 ± 0.2 vs. 15.5 ± 0.5 pg/mL,12 hours: 13.7 ± 0.7 vs. 25.5 ± 0.6 pg/mL and 24 hours: 7.6 ± 0.5 vs. 16 ± 0.3 pg/mL, P< 0.001). After 3 months, the same group showed significantly higher left ventricle ejection fraction (LVEF %) i.e. 64.5 ± 5.7 vs. 56.5 ± 5.3 (P<0.05). There was no statistically significant difference between both groups of patients regarding incidence of major adverse cardiac events (MACE). In diabetic patients undergoing elective PCI, intracoronary Adenosine was associated with decreased incidence of PCI-related myocardial injury & improvement of LVEF% after 3 months.
LIM SY,BAE EH,JEONG MH,et al.Effect of combined intracoronary adenosis and nicordial on no-reflow phenomenon during percutaneous coronary intervention[J].Circulation,2004,109(10):1236-1243.
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ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
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
Acute effects of intracoronary tirofiban on no-reflow phenomena in patients with ST-segment elevated myocardial infarction undergoing primary percutaneous coronary intervention
, 许祥玉, 郭小梅
