Pharmacological Management of No Reflow During Percutaneous Coronary Intervention

Abstract

Angiographic no reflow is a recognized phenomenon during percutaneous coronary intervention (PCI). It usually follows successful lesion dilation and, by definition, it represents a reduction in epicardial coronary blood flow in the absence of identifiable dissection, obstruction or distal vessel cut off (indicative of distal embolisation). No reflow appears to be more commonly associated with PCI for acute myocardial infarction and PCI for saphenous vein graft occlusions. While the exact mechanism of no reflow is unknown, theoretical causes include local humoral and microembolic effects leading to microcirculatory dysfunction. As the process is multifactorial, various therapeutic strategies are required in different situations. The present day pharmacological management involves the use of vasodilators including nitrates, verapamil, papaverine, adenosine, nicardipine and sodium nitroprusside, but interestingly a vasoconstrictor like epinephrine may also have a role. Glycoprotein IIb/IIIa platelet receptors antagonist have shown a powerful de-thrombotic effect, and the intracoronary administration appears to be particularly promising. We review the pathogenesis of a reduced epicardial flow during PCI and focus on those drugs that have been studied for the treatment of no reflow. Although no double blind, randomized trial has been conducted to assess any of these agents, or to determine the appropriate dosage, we try to identify some useful conclusions from the published evidence.

Efficacy and Safety of Local Intracoronary Drug Delivery in Treatment of No‐Reflow Phenomenon: A Pilot Study

“…Use of a vasodilator to treat no‐reflow was first described by Wilson et al in 1989 who reported a favorable response to papaverine in a single patient. Since this time the effect of several different vasodilators on no‐reflow has been investigated including nitrates, verapamil, adenosine, nicardipine, and sodium nitroprusside, but interestingly a vasoconstrictor‐like epinephrine may also have a role through acting on β‐receptors to produce coronary vasodilatation . This study was conducted to compare local delivery of adrenaline ± verapamil in the distal coronary bed via perfusion balloon or selective microcatheter versus intracoronary route through the guiding catheter regarding safety and efficacy.…”

Short‐term Effect of Verapamil on Coronary No‐Reflow Associated With Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: A Systematic Review and Meta‐analysis of Randomized Controlled Trials

“…As the process is multifactorial, various therapeutic strategies are required in different situations. Current pharmacological management involves the use of vasodilators, including nitrates, verapamil, papaverine, adenosine, nicardipine, and sodium nitroprusside, but interestingly, vasoconstrictors such as epinephrine may also have a role . Verapamil is a calcium channel blocker (CCB) that improves vascular wall stress and increases myocardial perfusion by disrupting the movement of calcium (Ca 2+ ) through calcium channels in coronary arteries .…”

“…of vasodilators, including nitrates, verapamil, papaverine, adenosine, nicardipine, and sodium nitroprusside, but interestingly, vasoconstrictors such as epinephrine may also have a role. 3 Verapamil is a calcium channel blocker (CCB) that improves vascular wall stress and increases myocardial perfusion by disrupting the movement of calcium (Ca 2+ ) through calcium channels in coronary arteries. 4 Based on the mechanism of action of verapamil, this CCB agent has been widely used in catheter labs to prevent and treat coronary no-reflow.…”

Efficacy of Short‐Term High‐Dose Atorvastatin Pretreatment in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Meta‐analysis of Nine Randomized Controlled Trials

“…As the processes for no‐reflow and PMI are multifactorial, various therapeutic strategies are required in different situations. Current pharmacological management involves the use of antiplatelet agents, vasodilators, and statins …”

“…Current pharmacological management involves the use of antiplatelet agents, vasodilators, and statins. 3,4 Atorvastatin, the most widely used statin, in addition to its beneficial lipid modulation effects, exerts a variety of several so-called pleiotropic actions such as inhibiting inflammation, antiventricular remodeling, improving vascular endothelial function, and antioxidant effects. 5 Because of the multiple functions, atorvastatin therapy is associated with a significant reduction in cardiovascular morbidity and mortality both in primary and secondary prevention.…”