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

Abstract

Background: To evaluate the clinical efficacy and safety of intracoronary verapamil injection in the prevention and treatment of coronary no-reflow after percutaneous coronary intervention (PCI). Hypothesis: Intracoronary verapamil injection may be beneficial in preventing no-reflow/slow-flow after PCI. Methods: We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials database. Randomized trials comparing the efficacy and safety of intracoronary verapamil infusion vs control in patients with acute coronary syndrome (ACS) were included. Meta-analysis was performed by RevMan 5.0 software (Cochrane Collaboration, Copenhagen, Denmark) . Results: Seven trials involving 539 patients were included in the analysis. Verapamil treatment was significantly more effective in decreasing the incidence of no-reflow (risk ratio [RR]: 0.33; 95% confidence interval [CI]: 0.23 to 0.50) as well as reducing the corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) (weighted mean difference: −11.62; 95% CI: −16.04 to −7.21) and improving the TIMI myocardial perfusion grade (TMPG) (RR: 0.43; 95% CI: 0.29 to 0.64). Verapamil also reduced the 30-day wall motion index (WMI) compared to the control. Moreover, the procedure reduced the incidence of major adverse cardiac events (MACEs) in ACS patients during hospitalization (RR: 0.37; 95% CI: 0.17 to 0.80) and 2 months after PCI (RR: 0.56; 95% CI: 0.33 to 0.95). However, administration of verapamil did not provide an additional improvement of left ventricular ejection fraction regardless of the time that had passed post-PCI. Conclusions: Intracoronary verapamil injection is beneficial in preventing no-reflow/slow-flow, reducing CTFC, improving TMPG, and lowering WMI. It is also likely to reduce the 2-month MACEs in ACS patients post-PCI.

Prevention of medical malpractice and disputes through analysis of lawsuits related to coronary angiography and intervention

“…Generally, the cause of a no-reflow phenomenon is likely multifactorial due to a combination of endothelial damage, platelet and fibrin embolization, vasospasm, and extracellular or intracellular tissue edema, ultimately leading to neutrophil plugs and platelet infiltration of myocardial tissue and microcirculation injuries [19]. At first, very selective and distal intracoronary or intravenous vasodilator such as adenosine [20,21], nicorandil [22], nitroprusside, nicardipine, or verapamil [23,24] is tried. Otherwise, epinephrine may be helpful [25,26].…”

A Risk Score for No Reflow in Patients With ST‐Segment Elevation Myocardial Infarction After Primary Percutaneous Coronary Intervention

“…The etiology of NRF is not yet fully understood, but it is assumed to be of multifactorial origin. Previous studies have identified several factors associated with NRF phenomenon, including plasma glucose, age, and pre‐PCI thrombus score . However, there is no screening tool to predict individual risk of developing NRF and to help health professionals make a decision on further intervention and select eligible patients into protocols focusing on mechanism and therapy of NRF.…”

Improving myocardial injury, infarct size, and myocardial salvage in the era of primary PCI for STEMI

“…A recent study of 108 patients with STEMI undergoing PPCI showed that a combination of intracoronary anisodipine (1 mg/5 ml) and diltiazem (2 mg/5 ml) reduced the rate of no-reflow/slow flow compared with diltiazem (2 mg/5 ml) alone [19]. A recent meta-analysis of seven randomized trials (539 patients with acute coronary syndromes undergoing PCI) showed that verapamil reduced the incidence of no-reflow, TIMI frame count, TIMI myocardial perfusion grade, and the 30-day wall motion index [61]. However, evidence on the use of these agents in the setting of PPCI remains limited.…”