Angiographic No-reflow Phenomenon Research Articles

Risk assessment score of no-reflow phenomenon in predicting myocardial perfusion disorders by contrast echocardiography in ST-segment elevation myocardial infarction patients after endovascular revascularization

Aim. To study the capabilities of risk assessment score for angiographic no-reflow phenomenon in predicting myocardial perfusion disorders according to contrast echocardiography data in ST-segment elevation myocardial infarction (STEMI) patients after percutaneous coronary interventions (PCI).Material and Methods. A total of 40 STEMI patients after PCI were included in the analysis. The individual risk score for noreflow phenomenon was calculated using previously developed scale in all patients. Risk of no-reflow was assessed as high when the score was ≥ 35. All patients underwent contrast echocardiography with myocardial perfusion assessment within six hours after PCI. The clinical angiographic characteristics and in-hospital outcomes were analyzed including the lethality, myocardial infarction recurrence, and stent thrombosis rates.Results. High risk of no-reflow phenomenon was identified in 13 (32.5%) patients. The rates of angiographic no-reflow phenomenon (46.2% versus 11.1%, p = 0.038) as well as contrast-enhanced echocardiography-based myocardial perfusion disorders (61.5% versus 18.5%, p = 0.011) were significantly higher in the high-risk patient group. According to results of ROCanalysis, no-reflow risk assessment scale for identifying patients with myocardial perfusion disorders according to contrast echocardiography had sensitivity/specificity/area under the curve (AUC) of 62%/85%/0.789 (p = 0.003).Conclusions. Angiographic no-reflow risk assessment score allowed to identify patients with high risk of developing myocardial perfusion disorders according to contrast echocardiography.

A score system to predict no-reflow in primary percutaneous coronary intervention: The PIANO Score.

Angiographic no-reflow is associated with poor outcomes in patients with ST-segment elevation myocardial infarction (STEMI). We sought to develop and validate a score system to predict angiographic no-reflow in primary percutaneous coronary intervention (PCI). ST-segment elevation myocardial infarction patients undergoing primary PCI were consecutively enrolled and were randomly divided into the training and validation set. Angiographic no-reflow was defined as thrombolysis in myocardial infarction (TIMI) flow grade 0 to 2 after PCI. In the training set, independent predictors were identified by logistic regression analysis, and a score system (PredIction of Angiographic NO-reflow, the PIANO score) was constructed based on the β-coefficient of each variable. The established model was evaluated for discrimination and calibration. Angiographic no-reflow occurred in 362 (17.8%) of 2036 patients. Age ≥70years, absence of pre-infarction angina, total ischaemic time ≥4h, left anterior descending as culprit artery, pre-PCI TIMI flow grade ≤1 and pre-PCI TIMI thrombus score ≥4 were independent predictors of angiographic no-reflow. The PIANO score ranged from 0 to 14 points, yielding a concordance index of 0.857 (95% confidence interval: 0.833 to 0.880), with good calibration. In the high-risk (≥8 points) group, the probability of angiographic no-reflow phenomenon was 38.7%, while it was only 4.8% in the low-risk (<8 points) group. The score system performed well in the validation set. We establish and validate a score system based on six clinical variables to predict angiographic no-reflow in STEMI patients undergoing primary PCI, which may help choose the optimal individual treatment strategy.

Vitamin D level predicts angiographic no-reflow phenomenon after percutaneous coronary intervention in patients with ST segment elevation myocardial infarction.

Aim: No-reflow phenomenon (NRP) is an undesirable result of coronary interventions, and usually occurred during the primary percutaneous coronary intervention (PPCI). On the other hand, there is growing evidence of epidemiological studies suggest that serum 25 hydroxy-vitamin D (25(OH)D3) level is significantly associated with cardiovascular mortality and morbidity. Objective: To investigate whether there is a relationship between admission serum 25(OH)D3 levels and NRP in patients with ST elevation myocardial infarction (STEMI). Methods: This study consisted of 496 consecutive acute STEMI patients who underwent PPCI. After the restoration of antegrade flow, the patients were divided into the normal flow and no-reflow groups. No-reflow defined as; thrombosis in myocardial infarction (TIMI) flow grade ≤2, or a TIMI flow grade=3 with a myocardial perfusion grade ≤1. Results: Angiographic no-reflow occurred 18.2% of all study patients. Serum 25(OH)D3 levels were significantly lower when compared with the normal flow group (14.6±7.3 vs 22.6±9.6ng/ml;p<0.001). 25(OH)D3 level was significantly negatively correlated with Neutrophil/lymphocyte (N/L) ratio. In multivariate analysis, 25(OH)D3 level on admission (OR: 0.738;95% CI: 0.584-0.878;p=0.001) was found an independent predictor of NRP together with N/L ratio, N-Terminal-proBNP, balloon pre dilatation and syntax score I. On receiver operating curve analysis (ROC), the cut-off value of admission 25(OH)D3 level was 10.5ng/ml for the prediction of NRP with a sensitivity of 93% and specificity of 68%. The area under the ROC curve (AUC) was 0.772 (95% CI: 0.697-0.846;p<0.001). Conclusion: We have shown that lower 25(OH)D3 level on admission is associated with higher NRP frequency and may be used as a predictor for NRP in STEMI patients undergoing PPCI.

Assessment of the Clinical and Procedural Predictive Factors ofNo-Reflow Phenomenon Following Primary Percutaneous CoronaryIntervention

AbstractBackground: Angiographic no-reflow phenomenon, areduced coronary antegrade flow (TIMI flow grade <-2) withoutmechanical obstruction after recanalization, predicts poor LVfunctional recovery and survival in the early phase of STEMI.Although the predisposing factors of the no-reflow phenom-enon were investigated, there is little data about clinical andprocedural predictors of this phenomenon.Aim of Study: The aim of this study was to evaluate theclinical and procedural predictive factors of no-reflow phe-nomenon following primary PCI.Patients and Methods: The present study was conductedon 145 patients admitted with STEMI and treated with 1ryPCI at Cardiovascular Medicine Department, Tanta UniversityHospitals within 6 months from June 2016 to December 2016.Patients were divided into 2 groups according to no-reflowphenomenon. Group I: 29 patients with no reflow phenomenon.Group II: 116 patients without no reflow phenomenon. Allpatients were subjected to an informed consent, history takingincluding personal history, risk factors including Hypertension (HTN), Diabetes Mellitus (DM), smoking, renal impairment.family history of premature coronary artery disease, pastmedical history of prior Myocardial Infarction (MI), Percuta-neous Coronary Intervention (PCI) or Coronary Artery BypassGraft (CABG), medications history, clinical examinationincluding vital signs, Body Mass Index (BMI), signs of heartfailure/hemodynamic instability according to Killip classifi-cation, signs of co-morbidities including renal/hepatic insuf-ficiency, diabetes. Local cardiac examination, twelve leadssurface ECG, echocardiography, blood sampling includingserum cardiac biomarkers, complete blood count, lipid profile (total cholesterol, HDL, LDL, triglycerides), random bloodsugar on admission, serum urea & creatinine on admission.Patients were subjected to diagnostic coronary angiographyand primary PCI.Results: The study demonstrated that there was a signif-icant association between angiographic no-reflow and old age, female gender, history of DM, prior MI, increased timeto reperfusion, higher Killip class, decreased LV ejectionfraction, increased blood CKMB, increased blood glucose,increased blood creatinine, the use of inotropes, initial TIMIflow grade 0, high thrombus burden and stenting with ballonpredilatation.Conclusion: The occurrence of no-reflow phenomenonafter primary PCI can be predicted using simple clinical,laboratory, angiographic and procedural features which includeold age, female gender, history of DM, prior MI, increasedtime to reperfusion, higher Killip class, decreased LV ejectionfraction, increased blood CKMB, increased blood glucose,increased blood creatinine, the use of inotropes, initial TIMIflow grade 0, high thrombus burden and stenting with ballonpredilatation.

Serum magnesium concentration may predict no-reflow phenomenon in primary angioplasty for ST-elevation myocardial infarction.

No-reflow phenomenon is a serious complication of percutaneous coronary intervention. Magnesium may play a role in pathogenesis of no-reflow phenomenon since it interacts with processes like platelet inhibition and endothelial-dependent vasodilatation. Relationship of serum magnesium concentration at admission and angiographic no-reflow phenomenon in ST elevation myocardial infarction patients undergoing primary percutaneous coronary intervention is investigated in the present study. A total of 2.248 consecutive patients with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention were analyzed. After reopening of the infarct related artery, a TIMI flow rate ≤ 2 was defined as no-reflow. No-reflow phenomenon developed in 386 (17.1 %) patients. Serum magnesium concentration was significantly lower in no-reflow group (1.87 ± 0.25 vs. 2.07 ± 0.33 mg/dL, p<0.001). ROC curve analysis showed that Mg at a cut-point of 1.92 has 71.4% sensitivity and 75.2% specificity in detecting no-reflow phenomenon. In multivariate logistic regression analysis, age, serum magnesium concentration, and stent length were found as independent predictors of no-reflow phenomenon. Serum magnesium concentration is associated with no-reflow phenomenon in ST elevation myocardial infarction patients who underwent primary PCI.

Circulating miR-660-5p is associated with no-reflow phenomenon in patients with ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

This study aims to investigate the association of circulating miR-660-5p with no-reflow phenomenon (NRP) in patients with ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Consecutive patients diagnosed with anterior STEMI within 12 h of pain onset were included; in these patients, coronary angiography confirmed that the left anterior descending artery was infarcted. Angiographic NRP was defined as a final thrombolysis in myocardial infarction (TIMI) flow 2 or 3 with a myocardial blush grade (MBG) <2. High miR-660-5p was defined as a value in the third tertile. The relationship of circulating miR-660-5p with NRP was assessed using Spearman correlation analysis and multiple logistic regression analysis. Fifty-two eligible patients were finally included in this study (mean age: 56±12.4 years, >65 years: 53.8%, male: 76.9%, and mean Body Mass Index: 26.3±3.5). The incidence of NRP was 38.5%. Circulating miR-660-5p was significantly related to the mean platelet volume (MPV). The patients were grouped into tertiles by miR-660-5p levels (Q1: <7.18, Q2: 7.18-11.31, Q3: >11.31). Those in the high microRNA-660-5p group had nearly a 6-fold higher risk of NRP than those in the low microRNA-660-5p group [odds ratio (OR) = 5.68, 95% confidence interval (CI) 1.40-23.07, p=0.015]. When analyzed by tertiles, relative odds of NRP were consistently increasing (OR1 for Q2 vs. Q1: 1.25, 95% CI: 0.27-5.73, p=0.770; OR2 for Q3 vs. Q1: 5.96, 95% CI: 1.33-26.66, p=0.02), despite multivariable adjustment. Receiver operating characteristic curve analysis demonstrated that the microRNA-660-5p level of 10.17 was the best cut-off level to predict the incidence of the NRP in patients undergoing PPCI with an area under the ROC curve (AUC) of 0.768 (95% CI: 0.636-0.890). Circulating miR-660-5p was significantly associated with NRP, and it may be a useful biomarker to predict the incidence of NRP in patients with STEMI undergoing PPCI.

Correlates of the “No-Reflow” or “Slow-Flow” Phenomenon in Patients Undergoing Primary Percutaneous Coronary Intervention

Background: Despite recent advances in interventional equipment and techniques, the angiographic no-reflow phenomenon occurs in a considerable number of patients undergoing primary percutaneous coronary intervention (PCI). We investigated the clinical, angiographic, preprocedural, and procedural characteristics associated with the no-reflow phenomenon among patients undergoing primary PCI. Methods: Between March 2008 and April 2013, 530 patients (78.5% male, mean age=58.11±12.39 y) with ST-segment-elevation myocardial-infarction who underwent primary PCI were categorized in 2 groups according to their postprocedural thrombolysis-in-myocardial infarction (TIMI) flow grades: those with a maximum score of 2 (the no-reflow or slow-flow group) and the ones with a score of 3 (the reflow group). A multivariable logistic regression model was used to find the multiple correlates of the no-reflow phenomenon after PCI. Results: There were 166 (31.3%) patients in the no-reflow group and 364 (68.7%) in the reflow group. The no-reflow patients were older and had significantly longer target lesion lengths, higher SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) scores, higher infarct-related artery SYNTAX scores, more thrombus burden, and a higher frequency of initial TIMI flow grades of 2 or lower. Our multivariable logistic regression analysis demonstrated that older age, higher numbers of Q waves, not using statin, longer target lesion lengths, higher thrombus grades, and higher infarct-related artery SYNTAX scores remained the independent correlates of increased no-reflow rates after primary PCI (area under the ROC curve=0.784, 95% CI: 0.742-0.826; P<0.001). Conclusion: Clinical, angiographic, and procedural features of patients undergoing primary PCI may be correlated with the occurrence of the no-reflow phenomenon. The thrombus grade and the infarct-related artery SYNTAX score could be among these factors.

The Impact of Admission Red Cell Distribution Width on Myocardial Perfusion and Short-Term Prognosis after Primary Percutaneous Coronary Intervention

RDW is a marker of the variability in erythrocyte Vol.ume and is a routinely available component of the complete blood count. Clinical usage of RDW has usually been restricted to differential diagnosis of anemia. However, elevated RDW levels are associated with poor prognoses in acute myocardial infarctions (MI) heart failures stable angina in patients undergoing PCI and general population even in the adjustment for multiple potential confounders, including anemia.The aim of this study is to evaluate the predictive value of red cell distribution width (RDW) on the electrocardiographic and angiographic no-reflow phenomenon in patients undergoing primary percutaneous coronary intervention (PCI).A total of 72 patients were included in this prospective cohort study. The study population was divided into two groups • Group (I): 54 patients with post-procedure ST-T resolution ≥ 50%. • Group (II): 18 patients with post-procedure ST-T resolution < 50%. Results of the current study showed that there was significant difference between the 2 groups regarding RDW (P= 0.003), LV systolic function (P= 0.040), TIMI flow after PPCI (P= 0.006) and MBG post PCI (P= 0.002). Also there was significant difference regarding in-hospital MACE (P= 0.023). Cut-off value for RDW as a predictor of outcome was ≥ 14.3 % with accuracy of 68% i.e. the higher the RDW the worse outcome result should be predicted out of PCI results. So, more focused care should be delivered to patients presented with STEMI and high RDW value.

Predictors of no- reflow during primary angioplasty for acute myocardial infarction, from Medical College Hospital, Trivandrum

BackgroundPrimary angioplasty (PCI) for acute myocardial infarction is associated with no-reflow phenomenon, in about 5–25% of cases. Here we analysed the factors predicting no reflow . MethodsThis was a case control study of consecutive patients with acute myocardial infarction who underwent Primary PCI from August 2014 to February 2015. ResultsOf 181 patients who underwent primary PCI, 47 (25.9%) showed an angiographic no-reflow phenomenon. The mean age was 59.19±10.25years and females were 11%.Univariate predictors of no reflow were age >60years (OR=6.146, 95%CI 2.937–12.86, P=0<0.001), reperfusion time >6h (OR=21.94, 95%CI 9.402–51.2, P=<0.001), low initial TIMI flow (≤1) (OR=12.12, 95%CI 4.117–35.65, P<0.001), low initial TMPG flow (≤1) (OR=36.19, 95%CI 4.847–270.2, P<0.001) a high thrombus burden (OR=11.04,95%CI 5.124–23.8, P<0.001), a long target lesion (OR=8.54, 95%CI 3.794–19.23, P<0.001), Killip Class III/IV(OR=2.937,95%CI 1.112–7.756,P=0.025) and overlap stenting(OR=3.733,95%CI 1.186–11.75,P=0.017).Multiple stepwise logistic regression analysis predictors were: longer reperfusion time>6h (OR=13.844, 95%CI 3.214–59.636, P=<0.001), age >60 years (OR=8.886, 95%CI 2.145–36.80, P=0.003), a long target lesion (OR=8.637, 95%CI 1.975–37.768, P=0.004), low initial TIMI flow (≤1) (OR=20.861, 95%CI 1.739–250.290, P=0.017). ConclusionsIt is important to minimize trauma to the vessel, avoid repetitive balloon dilatations use direct stenting and use the shortest stent if possible.

Association of monocyte count on admission with angiographic no-reflow after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction

The no-reflow phenomenon during primary percutaneous coronary intervention (pPCI) in patients with ST-elevation myocardial infarction (STEMI) can lead to poor outcomes. It has been shown that the monocytes may be involved in the pathogenesis of coronary artery disease and associated with high risk of myocardial infarction. To assess the relation between admission monocyte count and angiographic no-reflow after pPCI. A total of 236 patients with acute STEMI, who underwent pPCI, were enrolled. The patients were divided into two groups (no-reflow and normal reflow) based on post-pPCI Thrombolysis in Myocardial Infarction (TIMI) flow grade. No reflow was defined as TIMI flow grades ≤ 2, and normal reflow was defined as TIMI 3 flow grade. The monocyte count and other laboratory parameters were measured on admission before pPCI. There were 43 (18.2%) patients in the no-reflow group and 193 (81.8%) patients in the normal-reflow group. Patients with no-reflow had significantly higher admission monocyte count (0.76 ± 0.48 × 109/L vs. 0.55 ± 0.29 × 109/L, p = 0.004). Also, white blood cell and neutrophil counts were significantly higher while haemoglobin was significantly lower in the no-reflow group. In multivariate analysis, monocyte count remained an independent predictor of angiographic no-reflow phenomenon (odds ratio [OR] 2.665, 95% confidence interwal [CI] 1.102-6.445, p = 0.030) together with low haemoglobin concentration (OR 0.978, 95% CI 0.961-0.995, p = 0.013). Monocyte count on admission and low haemoglobin concentration were independent clinical predictors of no-reflow following pPCI in patients with STEMI. Our findings suggest that admission monocyte count may be available for early risk stratification of no-reflow after pPCI and might allow the improvement of strategies to prevent this phenomenon.

Relation of admission neutrophil/lymphocyte ratio to angiographic no-reflow phenomenon in patients with ST-elevated myocardial infarction undergoing primary coronary intervention

To investigate the relationship of the neutrophil/lymphocyte ratio (NLR) on admission and angiographic no-reflow phenomenon in patients with ST-segment elevation myocardial infarction (STEMI) who had undergone primary percutaneous coronary intervention (PCI). 232 patients who had undergone PCI between 2010 and 2013, were included and divided into two groups based upon the thrombolysis in myocardial infarction (TIMI) flow gradings. No-reflow was defined as post-PCI TIMI Grade 0, 1 and 2 flows (group I). Normal-flow was defined as TIMI 3 flow (group II). Receiver operating characteristic curve (ROC) analysis was used to identify the predictive effect of NLR on no-reflow phenomenon. Relationship of NLR and no-reflow was assessed by multivariate logistic regression. All statistical calculations and analyses were performed using SPSS 11.0. NLR was significantly higher in group I (n = 45) compared with group II (n = 187) [4.1(2.4-6.5) vs. 2.4 (1.7-3.8), P = 0.001]. In ROC analysis, NLR>3.2 predicted no reflow with 80% sensitivity and 73% specificity. Patients with elevated NLR had a higher incidence of no-reflow phenomenon than those with non-elevated NLR (34.8% vs. 9.3%, P < 0.001). Also, NLR (>3.2) was an independent predictor of no-reflow development [odds ratio 3.70, 95% confidence interval(1.39-9.80), P = 0.009]. NLR was an independent predicator for no-reflow development in STEMI patients who had undergone PCI. This simple and low-cost parameter could provide useful information for the early risk evaluation on these patients.

Prognostic significance of admission N-terminal pro-brain natriuretic peptide in predicting angiographic no-reflow phenomenon during percutaneous coronary intervention in patients with acute myocardial infarction

To determine the relationship between N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and angiographic no-reflow phenomenon in patients with acute myocardial infarction (AMI) after primary percutaneous coronary intervention (PCI). The data of 106 consecutive AMI patients undergoing primary PCl were collected and analyzed retrospectively. NT-proBNP was obtained pre-PCI at admission. According to the NT-proBNP level, they were divided into normal and elevated NT-proBNP groups. The no-reflow phenomenon was defined as an angiographic outcome of Thrombolysis In Myocardial Infarction (TIMI) grade < 3 without accompanying mechanical factors. The patients with elevated NT-proBNP on admission had a higher incidence of no-reflow phenomenon than those with NT-proBNP level. Compared to normal reflow counterparts, no-reflow patients had a higher NT-proBNP level [1883 ng/L (484 ∼ 5500 ng/L) vs 220 ng/L (87 ∼ 926 ng/L) P = 0.046]. Multivariate analysis showed that a high NT-proBNP level (NT-proBNP > 1765 ng/L) on admission was an independent predictor of no-reflow. This cut-off value yielded a sensitivity of 60.0% and a specificity of 87.5% respectively. The NT-proBNP level on admission may be a prognostic biomarker in the prediction of the development of angiographic "no-reflow" phenomenon after primary PCI for AMI patients.

Incidence and Outcomes of No-Reflow Phenomenon During Percutaneous Coronary Intervention Among Patients With Acute Myocardial Infarction

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.

Cavity volume of ruptured plaque is an independent predictor for angiographic no-reflow phenomenon during primary angioplasty in patients with ST-segment elevation myocardial infarction

Plaque rupture plays a critical role for the development of acute myocardial infarction. However, whether quantitative parameters with regard to the cavity size of ruptured plaque are associated with no-reflow (NR) phenomenon following primary angioplasty remains to be elucidated. A total of 53 patients with de novo ST-elevation myocardial infarction (STEMI) who had plaque rupture at the culprit lesion defined by pre-intervention virtual histology intravascular ultrasound (VH-IVUS) were enrolled. Patients were divided into two groups according to the presence of NR phenomenon: NR group (n=19) and non-NR group (n = 34). By VH-IVUS, we evaluated cavity length, maximum area, and volume of ruptured plaque in culprit lesions. The cavity length, maximum area, and volume were significantly higher in the NR group than those of the non-NR group (4.8 ± 2.1 mm vs. 2.9 ± 4.8 mm, p < 0.001; 3.6 ± 1.4 mm² vs. 1.9 ± 0.5 mm², p < 0.001; 11.5 ± 6.3 mm³ vs. 3.7 ± 2.2 cm³, p < 0.001). A multiple logistic regression analysis revealed that the cavity volume was an independent risk for NR phenomenon. Receiver-operating characteristic analysis revealed that the cavity volume could predict NR phenomenon. The cavity size of ruptured plaque is closely associated with NR phenomenon in patients with STEMI. Evaluation of the cavity volume by VH-IVUS may provide useful information for the prediction of NR phenomenon.

Relationship between plaque composition and no-reflow phenomenon following primary angioplasty in patients with ST-segment elevation myocardial infarction—Analysis with virtual histology intravascular ultrasound

The angiographic no-reflow phenomenon after primary percutaneous coronary intervention (PCI) carries a poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). However, the type of plaque composition that associates with the angiographic no-reflow phenomenon remains unclear. A total of 44 patients with STEMI were enrolled in this study. After thrombectomy with an aspiration catheter, virtual histology intravascular ultrasound (VH-IVUS) of the infarct-related vessel was performed. Patients were divided into two groups according to final thrombolysis in myocardial infarction (TIMI) flow grade at the completion of PCI procedure. Complete reperfusion group (CR-group) was defined as final TIMI flow grade 3, and no-reflow group (NR-group) was defined as final TIMI flow < or = 2. The relationship between plaque composition and angiographic no-reflow phenomenon was analyzed. The angiographic no-reflow phenomenon was observed in 20 individuals. The summation of the percentage of fibrofatty+necrotic core and fibrofatty+dense calcium was significantly higher in the NR-group. Receiver-operating characteristics analysis revealed that the summation of the volume and percentage of fibrofatty+necrotic core (> 20.1 mm(3), 26.2%) and fibrofatty+dense calcium (> 20.0 mm(3), 22.6%) predict the angiographic no-flow phenomenon. The fibrofatty-rich component with necrotic core or dense calcium derived from VH-IVUS is closely related to the angiographic no-reflow phenomenon observed in primary PCI.

AS-100: Value of N-Terminal Pro-Brain Natriuretic Peptide in Predicting Angiographic No-Reflow Phenomenon after Primary Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction

Previous studies have shown that failure to achieve thrombolysis in myocardial infarction (TIMI) flow grade 3 after successful opening of the artery without angiographic evidence of mechanical obstruction is observed in 5%–20% of acute myocardial infarction (AMI) patients treated with primary percutaneous coronary intervention (PCI). This is known as no-reflow phenomenon, which determines the prognosis in patients after AMI. The value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in terms of diagnosis and prognosis in congestive heart failure and left ventricular systolic dysfunction has been demonstrated previously, but it has not been specified whether ventricular dysfunction and other cardiac processes, such as myocardial ischemia, acute coronary syndrome, valvular heart disease, and other cardiac pathologies may also cause elevation of this marker.

Angiographic No‐Reflow Phenomenon and Plaque Characteristics by Virtual Histology Intravascular Ultrasound in Patients with Acute Myocardial Infarction

This study aimed to evaluate the relationship between the occurrence of the angiographic no-reflow phenomenon in patients with acute myocardial infarction (AMI) and the preintervention plaque composition as assessed by virtual histology intravascular ultrasound (VH-IVUS). The angiographic no-reflow phenomenon is an adverse prognostic factor in patients with AMI. We enrolled consecutive 50 patients with ST-elevation AMI was treated by primary stent implantation. All culprit lesions were imaged by VH-IVUS before stent implantation. The angiographic no-reflow phenomenon was defined as a decrease in final TIMI flow grade compared with TIMI flow grade before stent implantation. Eight of 50 patients developed angiographic no-reflow after stent implantation. Gray-scale intravascular ultrasound (IVUS) showed significantly larger external elastic membrane volume and plaque burden in the no-reflow group. VH-IVUS showed a trend toward larger percentage of fibro-fatty plaque volume in the no-reflow group than in the reflow group (23.1 +/- 3.5 vs. 17.0 +/- 1.1%, P = 0.05). The presence of "marble"-like image, mainly consisting of fibro-fatty and fibrous plaque (plaque volume of fibro-fatty + fibrous >80% and containing fibro-fatty plaque volume >10%) was associated with angiographic no-reflow (P = 0.02). Corrected TIMI frame counts of the cases with "marble"-like image were significantly larger than the cases without it (46.8 +/- 5.6 vs. 27.4 +/- 2.3, P = 0.01). The culprit lesions with large plaque burden, or with "marble"-like image by VH-IVUS, are associated with the angiographic no-reflow phenomenon in patients with AMI.

Usefulness of Preprocedural N-Terminal Pro-Brain Natriuretic Peptide in Predicting Angiographic No-Reflow Phenomenon During Stent Implantation in Patients With ST-Segment Elevation Acute Myocardial Infarction

The no-reflow phenomenon after primary percutaneous coronary intervention (PCI) is associated with larger infarct size, worse functional recovery, and higher incidence of complication after acute ST-elevation myocardial infarction (STEMI). The aim of this study was to assess the relation between preprocedural N-terminal pro-brain-type natriuretic peptide (NT-pro-BNP) and angiographic no-reflow phenomenon. We measured preprocedural serum NT-pro-BNP level in 159 consecutive patients with acute STEMI (aged 63 +/- 12 years; 72% men) before PCI. Angiographic no-reflow after PCI was defined as Thrombolysis In Myocardial Infarction (TIMI) flow grade <3. Baseline characteristics, including time from chest pain onset, between the no-reflow (n = 67) and normal-reflow groups (n = 92) were similar. NT-pro-BNP was significantly higher in the no-reflow group than the normal reflow group (1,982 +/- 3,314 vs 415 +/- 632 pg/ml; p = 0.005). Also, high-sensitivity C-reactive protein, monocytes, and troponin-T were significantly higher in the no-reflow group than the normal-reflow group. In the no-reflow group, NT-pro-BNP was much higher in patients with TIMI flow grade 0 (n = 41; 2,290 +/- 3,495 pg/ml) than those with TIMI grade 1 or 2 (n = 26; 1,575 +/- 2,340 pg/ml), but without significant difference. The area under the receiver-operating characteristic curve for NT-pro-BNP was 0.78, and the optimal cut-off value identified using receiver-operating characteristic curve analysis was 500 pg/ml. At the standard cut-off value of >500 pg/ml, increased NT-pro-BNP showed a high probability of no-reflow phenomenon (odds ratio 4.42, 95% confidence interval 1.15 to 17.00, p = 0.028). In conclusion, preprocedural NT-pro-BNP may be a strong predictor of the development of no-reflow phenomenon after PCI in patients with acute STEMI.

PO17-505 PREDICTORS OF SLOW FLOW DURING PERCUTANEOUS CORONARY INTERVENTION: AN IVUS STUDY

The angiographic no-reflow phenomenon after primary percutaneous coronary intervention (PCI) carries a poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). However, the type of plaque composition that associates with the angiographic no-reflow phenomenon remains unclear.A total of 44 patients with STEMI were enrolled in this study. After thrombectomy with an aspiration catheter, virtual histology intravascular ultrasound (VH-IVUS) of the infarct-related vessel was performed. Patients were divided into two groups according to final thrombolysis in myocardial infarction (TIMI) flow grade at the completion of PCI procedure. Complete reperfusion group (CR-group) was defined as final TIMI flow grade 3, and no-reflow group (NR-group) was defined as final TIMI flow ≦2. The relationship between plaque composition and angiographic no-reflow phenomenon was analyzed.The angiographic no-reflow phenomenon was observed in 20 individuals. The summation of the percentage of fibrofatty + necrotic core and fibrofatty + dense calcium was significantly higher in the NR-group. Receiver-operating characteristics analysis revealed that the summation of the volume and percentage of fibrofatty + necrotic core (>20.1 mm3, 26.2%) and fibrofatty + dense calcium (>20.0 mm3, 22.6%) predict the angiographic no-flow phenomenon.The fibrofatty-rich component with necrotic core or dense calcium derived from VH-IVUS is closely related to the angiographic no-reflow phenomenon observed in primary PCI.

Effects of Intraaortic Balloon Pumping on the Angiographic No-Reflow Phenomenon After Percutaneous Coronary Intervention in Patients With Anterior Myocardial Infarction

The effects of intraaortic balloon pumping (IABP) are considered to be a reduction in myocardial oxygen demand because of systolic left ventricular unloading and an increase in coronary blood flow. Although the former effect has been consistently recognized, the latter effect remains controversial. The purpose of this study was to examine the effects of IABP on the angiographic no-reflow phenomenon. The coronary flow velocity pattern of the left anterior descending artery (LAD) was assessed by transthoracic Doppler echocardiography during IABP counterpulsation, and the effects of IABP were compared between angiographic no-reflow and good reflow patients. The study group comprised 17 patients with anterior myocardial infarction who underwent percutaneous coronary intervention and IABP for typical clinical indications. Echocardiographic data were obtained during 2:1 balloon pumping after coronary angioplasty. In the good reflow group (n=9), IABP counterpulsation increased the mean diastolic flow velocity (MDFV) and peak diastolic flow velocity (PDFV) by 56 +/- 32% (p<0.001) and 48 +/- 27% (p<0.001), respectively. In contrast, in the no-reflow group (n=8), IABP only increased the MDFV and PDFV by 19 +/- 33% (p=0.24) and 6 +/- 12% (p=0.22), respectively. Diastolic deceleration time was smaller and the prevalence of systolic retrograde flow was greater in the no-reflow group than in the good reflow group, and IABP affected neither parameter. IABP had limited effects on LAD flow velocity pattern in patients with the angiographic no-reflow phenomenon.