Intracoronary Administration Of Nicorandil Research Articles

A pilot study of perfusion balloon predilatation in conjunction with intracoronary nicorandil administration for acute coronary syndrome.

Slow-flow or no-reflow phenomenon is a common procedural complication during percutaneous coronary intervention (PCI). Given the presence of fragile plaque or thrombotic materials, we hypothesized that long-time predilatation using a perfusion balloon in conjunction with intracoronary nicorandil administration reduces the risk of slow-flow or no-reflow in patients presenting with acute coronary syndrome (ACS). Subjects were patients presenting with ACS who underwent PCI between April 2020 and April 2022. We retrospectively investigated the incidence of slow-flow or no-reflow during the procedure as well as in-hospital outcomes in comparison between the cases undergoing 3-min predilatation using a perfusion balloon in conjunction with intracoronary nicorandil administration followed by DES implantation (PB group) and those with direct stenting (DS group). Among 439 ACS patients, 36 patients in the PB group and 51 patients in the DS group were examined. Mean age was 70years and 78.2% was male. Distal protection devices were more frequently used in the DS group than in the PB group (31.3% vs. 11.1%, p = 0.02). The incidence rate of slow-flow or no-reflow was significantly lower in the PB group than in the DS group (2.8% vs. 23.5%; p < 0.01). Six cases (11.7%) in the DS group required intra-aortic balloon pumping (IABP), while none in the PB group required (p < 0.01). In-hospital clinical outcomes did not differ between the two groups. Prolonged perfusion balloon predilatation in conjunction with intracoronary nicorandil administration was safe and feasible. This novel strategy could be an attractive alternative to conventional direct stenting for ACS patients.

Assessment of the Efficacy and Safety of Early Intracoronary Nicorandil Administration in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

BackgroundNo-reflow phenomenon (NRP) remains a challenge in ST-elevation myocardial infarction (STEMI) patients. We determined the efficacy and safety of early intracoronary administration of nicorandil as an adjunct to primary percutaneous coronary intervention (pPCI) in STEMI patients to reduce the risk of NRP.Materials and methodsIn this single-center case-control prospective study, 100 STEMI patients who underwent pPCI had thrombectomy performed using a suction catheter, and tirofiban (10 mg/kg) was injected distal to the vascular lesion. All patients were divided into two groups. Group A was a treatment group (nicorandil, n=50) and group B was a control group (placebo, n=50). The primary endpoint was the composite endpoint of in-hospital cardiovascular mortality or unscheduled re-hospitalization due to deterioration of congestive heart failure that was assessed with the help of brain natriuretic peptide (BNP), left ventricular end-diastolic diameter (LVEDD), and left ventricular ejection fraction at six months following pPCI. The secondary endpoints were thrombolysis in myocardial infarction (TIMI) flow grade, TIMI myocardial perfusion grade (TMPG), the incidence of reperfusion arrhythmias like ventricular tachycardia and ventricular fibrillation, and ST segment elevation resolution (STR) on ECG following pPCI.ResultsThe in-hospital cardiovascular mortality and re-hospitalization rates were 2% and 6% in the nicorandil group, whereas it was 6% and 14% in the control group. On the 180th day of admission, the nicorandil group had significantly lower values of brain natriuretic peptide (348.45±112.32 pg/ml vs. 541.11±152.68 pg/ml, p=0.021) and left ventricular end-diastolic diameter (54.12±3.56 mm vs. 60.62±4.98 mm, p=0.011) than the control group. Nicorandil group had a significantly higher number of patients who attained TIMI 3 (p=0.022), TMPG 3 (p=0.034), and STR (p=0.008) than the control group. Ventricular arrhythmia was significantly lower in the nicorandil group than in the control group at 24 hours following pPCI (p=0.012).ConclusionEarly intracoronary administration of nicorandil during pPCI may decrease the occurrence of NRP, in-hospital cardiovascular mortality, and re-hospitalization rates, as well as improve coronary blood flow and reduce reperfusion arrhythmia in STEMI patients.

Myocardial protective effect of intracoronary administration of nicorandil and alprostadil via targeted perfusion microcatheter in patients undergoing elective percutaneous coronary intervention: A randomized controlled trial.

Background:The aim of the study was to evaluate the efficacy of nicorandil and alprostadil on myocardial protection in patients undergoing elective percutaneous coronary intervention (PCI).Methods:In this prospective, single-blinded, randomized controlled study, 90 consecutive patients scheduled for elective PCI for de novo coronary lesions were assigned to the nicorandil, alprostadil, and nitroglycerin groups in a 1:1:1 ratio. Drugs were administered intracoronary via a targeted perfusion microcatheter. The primary endpoint was the thrombolysis in myocardial infarction (TIMI) myocardial perfusion frame count (TMPFC). Additionally, the corrected TIMI frame count (cTFC), TIMI myocardial perfusion grade (TMPG), and incidence of periprocedural myocardial injury (PMI) were assessed.Results:Both nicorandil and alprostadil were significantly effective in reducing TMPFC (114.6 ± 33.7 vs 93.4 ± 30.9, P = .016; 114.3 ± 34.3 vs 94.7 ± 33.3, P = .029, respectively). Similar findings were observed in the improvement of cTFC (20.3 ± 10.5 vs 13.5 ± 5.0, P = .003; 20.2 ± 7.4 vs 15.2 ± 5.2, P = .003, respectively) and percentage of TMPG 3 (100% vs 82.8%, P = .052; 83.3% vs 96.7%, P = .196, respectively); whereas, nitroglycerin produced a limited effect on TMPFC (114.4 ± 30.9 vs 112.1 ± 31.9, P = .739), cTFC (19.4 ± 7.2 vs 19.3 ± 7.2, P = .936), and percentage of TMPG 3 (86.7% vs 86.7%, P = 1.000). No significant difference was found in the incidence of PMI (16.7% vs 16.0% vs 27.6%, P = .537), though it was comparatively lower in the nicorandil and alprostadil groups. Furthermore, the intracoronary administration of nicorandil and alprostadil had a mild effect on blood pressure and heart rate.Conclusions:The intracoronary administration of nicorandil and alprostadil via a targeted perfusion microcatheter was more effective in improving myocardial perfusion in patients undergoing elective PCI than nitroglycerin.

Influence of caffeine intake on intravenous adenosine-induced fractional flow reserve

Abstract Background This study evaluated whether caffeine abstention is required before fractional flow reserve (FFR) measurement by intravenous adenosine triphosphate (ATP) administration in Japanese patients. Methods and results This study was a subanalysis of a previously published study and a total of 208 intermediate lesions that underwent FFR measurements were enrolled for this analysis. Hyperemia was induced by continuous intravenous ATP infusion at 150μg/kg/min (IVATP150) and 210μg/kg/min (IVATP210), and by intracoronary administration of nicorandil 2mg (ICNIC2mg) as a reference standard. The degree of change in the FFR value both after IVATP150 and after IVATP210, as compared with the FFR value after ICNIC2mg was similar between the caffeine and non-caffeine groups (−0.04±0.05 vs. −0.04±0.07, and 0.00±0.02 vs. 0.01±0.02, respectively). In patients who consumed caffeine before the FFR measurement, the degree of FFR change was independent of the time interval (&amp;lt;12 hours, 12–24 hours, and 24–48 hours) between caffeine intake and catheterization both after IVATP150 and ICNIC2mg and after IVATP210 and ICNIC2mg. Conclusion When compared with the FFR value after ICNIC2mg, the degree of change in the FFR value both after IVATP150 and after IVATP210 remained similar regardless of caffeine intake. Strict caffeine abstention before intravenous ATP-induced FFR measurement may not be required in clinical practice. Funding Acknowledgement Type of funding source: None

Influence of caffeine intake on intravenous adenosine-induced fractional flow reserve

BackgroundThis study evaluated whether caffeine abstention is required before fractional flow reserve (FFR) measurement by intravenous adenosine triphosphate (ATP) administration in Japanese patients. MethodsThis study was a subanalysis of a previously published study and a total of 208 intermediate lesions that underwent FFR measurements were enrolled for this analysis. Hyperemia was induced by continuous intravenous ATP infusion at 150 μg/kg/min (IVATP150) and 210 μg/kg/min (IVATP210), and by intracoronary administration of nicorandil 2 mg (ICNIC2mg) as a reference standard. ResultsThe degree of change in the FFR value after ICNIC2mg and IVATP210 was similar between the caffeine and non-caffeine groups (0.00 ± 0.02 vs. 0.01 ± 0.02). In patients who consumed caffeine before the FFR measurement, the degree of FFR change was independent of the time interval (<12 h, 12–24 h, and 24–48 h) between caffeine intake and catheterization both after IVATP150 and ICNIC2mg and after IVATP210 and ICNIC2mg. ConclusionWhen compared with the FFR value after ICNIC2mg, the degree of change in the FFR value after IVATP210 were similar regardless of caffeine intake. Strict caffeine abstention before intravenous ATP-induced FFR measurement may not be required in clinical practice.

Intracoronary pressure gradient measurement in acute myocardial infarction patients with the no-reflow phenomenon during primary percutaneous coronary intervention.

BackgroundVarious experimental and clinical studies have reported on coronary microcirculatory dysfunction (“no-reflow” phenomenon). Nevertheless, pathogenesis and effective treatment are yet to be fully elucidated. This study aimed to measure the intracoronary pressure gradient in the no-reflow artery during emergent percutaneous coronary intervention and explore the potential mechanism of no-reflow.MethodsFrom September 1st, 2018 to June 30th, 2019, intracoronary pressure in acute myocardial infarction patient was continuously measured by aspiration catheter from distal to proximal segment in the Department of Coronary Care Unit, Tianjin Chest Hospital, respectively in no-reflow arteries (no-reflow group) and arteries with thrombolysis in myocardial infarction-3 flow (control group). At least 12 cardiac cycles were consecutively recorded when the catheter was pulled back. The forward systolic pressure gradient was calculated as proximal systolic pressure minus distal systolic pressure. Comparison between groups was made using the Student t test, Mann-Whitney U-test or Chi-square test, as appropriate.ResultsIntracoronary pressure in 33 no-reflow group and 26 in control group were measured. The intracoronary forward systolic pressure gradient was −1.3 (−4.8, 0.7) and 3.8 (0.8, 8.8) mmHg in no-reflow group and control group (Z = −3.989, P < 0.001), respectively, while the forward diastolic pressure gradient was −1.0 (−3.2, 0) and 4.6 (0, 16.5) mmHg in respective groups (Z = −3.851, P < 0.001). Moreover, the intracoronary forward pressure gradient showed significant difference between that before and after nicorandil medication (Z = −3.668, P < 0.001 in systolic pressure gradient and Z = −3.530, P < 0.001 in diastolic pressure gradient).ConclusionsNo reflow during emergent coronary revascularization is significantly associated with local hemodynamic abnormalities in the coronary arteries. Intracoronary nicorandil administration at the distal segment of a coronary artery with an aspiration catheter could improve the microcirculatory dysfunction and resume normal coronary pressure gradient.Clinical trial registrationwww.ClinicalTrials.gov (No. NCT 03600259).

Evaluation of Cardioprotective Effect of a Single Oral Dose of Nicorandil before Primary PCI in Patients presenting with Anterior STEMI

Abstract Background Nicorandil in conjunction with primary percutaneous coronary intervention (PPCI) has been reported to exert cardioprotective effect in patients with ST segment elevation myocardial infarction (STEMI). Intravenous and intracoronary Nicorandil administration with PPCI have been reported to reduce reperfusion injury consequences and improve cardiac function in patients with STEMI even on the long term .However, there is limited information on the cardioprotective effect of oral Nicorandil in STEMI patients . Objective The Aim of this study was to evaluate Cardioprotective effect of a single oral dose of Nicorandil 20 mg given before primary PCI in patients presenting with a first anterior STEMI within 6 hours from symptoms onset. Material and Methods This study is a Prospective multicenter Study that included 80 Patients who were presenting with first anterior STEMI and undergone primary PCI as a myocardial reperfusion method in the period between June 2016 and May 2018. Patients were divided into two groups: Group A (40 patients) was the Study group which received Nicorandil 20mg single oral dose immediately on admission with the loading doses of aspirin and clopidogril prior to the PPCI procedure and Group B (40 patients) was the Control group that did not receive Nicorandil . Results There were no statistically significant differences between two groups as regards demographic data, risk factors for coronary artery disease and procedural data . There was statistically significant lower peak levels of cardiac enzymes and higher left ventricle ejection fraction (LVEF%) in group (A) compared to group (B). The peak level of CKT in group (A) was 1899.1± 601.000 compared to 2386.300 ± 844.318 in group (B), (P = 0.004) .The peak level of CK MB in group (A) was 264.100 ± 86.982 compared to 329.325 ± 147.404 in group (B), (P = 0.018) .The LVEF% in group (A) was (43.550±5.114) compared to (40.325±5.753) in group (B), (P = 0.010). Conclusion Single dose of Nicorandil 20 mg administered orally and given to patients who were presenting with a first anterior STEMI within 6 hours from symptoms onset prior to reperfusion with primary PCI had a significant cardioprotective effect in the form of higher left ventricular ejection fraction and lesser release of cardiac enzymes (CKT and CK MB) compared to control group which reflects more myocardial salvage of the area at risk and lesser reperfusion induced myocardial damage.

P18 The utility and validity of intracoronary administration of nicorandil alone for the measurement of fractional flow reserve in patients with intermediate coronary stenosis

Abstract Backgrand Recently, intracoronary nicorandil (ICN) administration in addition to intravenous adenosine 5"-triphosphate (IVATP) is generally used to achieve maximal hyperemia for evaluating fractional flow reserve (FFR). This study investigated the usefulness and safety of ICN alone compared with IVATP and ICN during IVATP for the achievement of maximal hyperemia in patients with suspected angina pectoris. Methods Two-hundred-ten angiographically intermediate lesions in two-hundred-seven patients who underwent FFR assessments were enrolled. FFR was measured after ICN (2mg/5seconds), IVATP (150µg/kg/min) for 2 minutes, IVATP (210µg/km/min) for 2 minutes, and ICN (2mg/5seconds) during IVATP (150µg/kg/min). Maximal hyperemia was defined as the lowest FFR measured among each method. Results During the protocol, 92% of patients achieved maximal hyperemia with ICN2mg, 54% with IVATP 150µg/kg/min, 91% with IVATP 210µg/kg/min, and 99% with ICN2mg during IVATP 150µg/kg/min, respectively. The FFR obtained with ICN2mg were strongly correlated with those obtained with ICN2mg during IVATP150µg/kg/min (r²=0.93, P&amp;lt; 0.001). The mean aortic pressure drop during hyperemia was significantly lower in ICN2mg than in IVATP 150µg/kg/min, IVATP 210µg/kg/min, and ICN2mg during IVATP 150µg/kg/min(9 ± 10, 11 ± 14, 24 ± 17, and 27 ± 19mmHg, p &amp;lt; 0.001, respectively). Despite no side effects reported during hyperemia with ICN2mg alone, transient atrioventricular block was observed in 1(1%) patient with IVATP 150µg/kg/min and 9(4%) patients with IVATP 210µg/kg/min. Also, 20 (10%) patients with IVATP 150µg/kg/min and 56(27%) with IVATP210µg/kg/min experienced chest discomfort during hyperemia. Conclusions The intracoronary administration of NIC2mg is safe and well tolerated, and shortens the procedure. Furthermore, intracoronary NIC2mg produced a more pronounced hyperemia than IVATP and may be the preferred mode of application for the assessment of FFR.

Effects of Intracoronary Nicorandil on Myocardial Microcirculation and Clinical Outcomes in Patients with Acute Myocardial Infarction: A Meta-Analysis of Randomized Controlled Trials.

The amelioration of myocardial reperfusion in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PPCI) remains a significant issue. We conducted a meta-analysis of randomized controlled trials (RCTs) to better assess the effects of intracoronary nicorandil administration on myocardial microcirculation and clinical outcomes in these patients. The meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. A literature search was performed in the PubMed, Embase, Cochrane Library, and Web of Science databases up to April 2019, with no time or language limitations. Pooled risk ratios (RRs) were calculated to evaluate the treatment effects. Seven RCTs involving a total of 562 patients were included. Compared with control, intracoronary nicorandil significantly reduced the incidence of thrombolysis in myocardial infarction (TIMI) grade ≤ 2 (RR 0.349; 95% confidence interval [CI] 0.199-0.611; P < 0.001) and TIMI myocardial perfusion grade ≤ 2 (RR 0.611; 95% CI 0.438-0.852; P = 0.004) and was associated with higher complete ST-segment resolution rates (RR 1.326; 95% CI 1.090-1.614; P = 0.005). However, no significant benefits were observed on clinical outcomes, including death (RR 0.370; 95% CI 0.085-1.618; P = 0.187), recurrent myocardial infarction (RR 0.507; 95% CI 0.156-1.655; P = 0.261), heart failure (RR 0.528; 95% CI 0.224-1.247; P = 0.145), and target lesion/vessel revascularization (RR 1.109; 95% CI 0.553-2.224; P = 0.770). Intracoronary nicorandil can significantly improve myocardial microcirculation in patients with AMI undergoing PPCI, but it failed to offer clinically significant benefits.

Effects of Early Intracoronary Administration of Nicorandil During Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction

To determine whether nicorandil administration distal to the thrombus in the coronary artery during percutaneous coronary intervention (PCI) in acute ST-segment elevation myocardial infarction (STEMI) patients reduced the incidence of no-reflow phenomenon, reperfusion injury, and adverse events. This randomised controlled trial involved 170 STEMI patients who underwent PCI. All patients underwent thrombectomy and tirofiban injection (10μg/kg) distal to the vascular lesion via a suction catheter, followed by nicorandil (84 patients; 2mg) or saline injection (86 patients; 2mL) at the same site. The primary endpoint (major adverse cardiac events, MACEs) was 6-month cardiovascular mortality or unplanned readmission rate due to worsening congestive heart failure. The secondary endpoints were thrombolysis in myocardial infarction (TIMI) grade, TIMI myocardial perfusion grade (TMPG), resolution of ST-segment elevation (defined as >50% decrease in ST elevation); and ventricular arrhythmias. Upon Kaplan-Meier analysis, freedom from MACEs was 92.9% in the nicorandil group and 81.4% in the placebo (p=0.026). The numbers of patients achieving TIMI grade 3 (95.24% vs. 86.05%; p=0.040) and TMPG 3 (94.05% vs. 83.72%; p=0.033) were greater in the nicorandil group than in the control group. Resolution of ST-segment elevation occurred in 84.52% and 68.60% patients in the nicorandil and control groups, respectively (p=0.014). Ventricular arrhythmias occurred in 5.95% and 16.28% patients in the nicorandil and control groups, respectively (p=0.032). Early administration of nicorandil distal to the vascular lesion during PCI in STEMI patients may reduce the incidence of reperfusion injury, and improve short-term clinical outcomes. NCT02435797.

Effect of nicorandil administration on myocardial microcirculation during primary percutaneous coronary intervention in patients with acute myocardial infarction.

IntroductionPrevention of the no-reflow phenomenon has a crucial role in primary percutaneous coronary intervention (P-PCI) procedures.AimTo assess the effects of early intracoronary administration of nicorandil (NIC) during P-PCI on myocardial microcirculation in patients with acute myocardial infarction (AMI).Material and methodsA total of 120 patients with first acute anterior wall ST segment elevation myocardial infarction who underwent P-PCI were randomly divided into two groups: the NIC group (A, n = 60) and the placebo group (B, n = 60). Before stent placement, NIC or normal saline was injected using a guiding catheter. The thrombolysis in myocardial infarction (TIMI) grade, TIMI myocardial perfusion grade (TMPG), resolution of ST segment elevation (defined as > 50% decrease in ST elevation) 1 h after surgery, and 99Tcm-methoxyisobutyl isocyanide (MIBI) rest myocardial perfusion imaging (MPI) via single-photon emission computed tomography (99Tcm-MIBI SPECT) findings 10 days after surgery were compared between the two groups.ResultsThe number of patients who achieved TIMI grade 3 (96.67% vs. 86.67%; p = 0.047) and TMPG 3 (95% vs. 83.33%; p = 0.040) was higher in the NIC group than in the placebo group. Resolution of ST segment elevation occurred in 95% and 81.67% of the patients in the NIC and placebo groups, respectively (p = 0.023); the MPI score of the two groups was 4.1 ±1.89 and 7.3 ±2.65, respectively (p = 0.014).ConclusionsEarly coronary administration of NIC can significantly reduce the damage in the myocardial microcirculation caused by P-PCI and the myocardial infarct size in patients with AMI.

The effect on myocardial perfusion and clinical outcome of intracoronary nicorandil injection prior to percutaneous coronary intervention in ST-segment elevation myocardial infarction

Objective: To investigate the effect of intracoronary administration of nicorandil prior to primary percutaneous coronary intervention (PPCI) on myocardial perfusion and short-term clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Methods: A total of 158 patients with STEMI undergoing PPCI from January 2014 to December 2015 in Fuzhou General Hospital were enrolled consecutively in this prospective controlled randomized trial. Patients were assigned into three groups with random number table: the nicorandil group (patients received intracoronary administration of 6 mg nicorandil after guide wire or balloon successfully crossed the target lesion, n=53), the nitroglycerin group (patients received intracoronary administration of 300 μg nitroglycerin after after guide wire or balloon successfully crossed the target lesion, n=52) and the control group(patients received routine treatment, n=53). The primary outcomes were myocardial perfusion, including the levels of corrected TIMI frame count (cTFC), and the incidence of no reflow or slow flow after PPCI. The secondary outcomes included the incidence of major adverse cardiovascular events (MACE) during hospitalization (all-cause death, reperfusion arrhythmia within 2 hours after PPCI, angina within 24 hours after PPCI, new heart failure or worsening cardiac function, and repeat revascularization) and within 3 months of follow-up (all-cause death, nonfatal myocardial infarction, repeat revascularization, post-infarction angina, and re-hospitalization for congestive heart failure). Results: The age of enrolled patients was (62.9±11.3) years old, and 130 cases (82.3%) of them were male. The median time of symptom-onset to balloon was 4.50 (3.20, 6.43) hours. There were significantly difference in cTFC immediately after PPCI((21.68±7.43)frames, (24.74±8.66)frames, and(27.06±10.40)frames), incidence of no reflow or slow flow after PPCI(5.7%(3/53), 13.5%(7/52), and 22.6%(12/53)), ST-segment resolution at 2 hours after procedure(90.6%(48/53), 84.6%(44/52), and 74.5%(38/53)), and reperfusion arrhythmia at 2 hours after procedure(15.1%(8/53), 36.6%(19/52), and 34.0%(18/53)) among the 3 groups(P<0.01 or 0.05). In the multivariate logistic regression models, intracoronary administration of nicorandil could lower the cTFC level (OR=0.17, 95%CI 0.10-0.41, P=0.001), acted as a protecting factor on lowering the incidence of no reflow or slow flow (OR=0.13, 95%CI 0.02-0.96, P=0.045) and reperfusion arrhythmia (OR=0.26, 95%CI 0.09-0.74, P=0.012), as well as facilitating the ST-segment resolution at 2 hours after procedure (OR=4.62, 95%CI 1.14-18.82, P=0.033). However, observed parameters were similar between intracoronary administration of nitroglycerin group compared with control group (all P>0.05). MACE within 3 months of follow-up were similar among the 3 groups(all P>0.05). Conclusion: Intracoronary administration of nicorandil prior to balloon dilation can significantly improve the myocardial perfusion and reduce the occurrence of reperfusion arrhythmia during PPCI for STEMI, but does not affect the short-term prognosis in STEMI patients.

Impact of additional intracoronary nicorandil administration during fractional flow reserve measurement with intravenous adenosine 5′-triphosphate infusion

BackgroundFractional flow reserve (FFR) is a useful index for determining the functional severity of epicardial coronary artery stenosis as an invasive physiological method. Although intravenous adenosine 5′-triphosphate (ATP) is generally used as a hyperemic agent for FFR measurement in Japan, there are some concerns about the variability of FFR measurement (short half-life, effect of caffeine, cyclic change). It is difficult to confirm sufficient maximum hyperemia after ATP infusion. Recent studies reported that nicorandil (NIC) could be an alternative to ATP as a hyperemic agent. MethodsPatients who underwent FFR assessments of angiographically intermediate lesions were included. All patients were asked to refrain from caffeine-containing products more than 12hours before FFR measurements. All patients first received intravenous (IV) ATP infusion (180μg/kg/min) for 3min to measure FFR (ATP-FFR). After additional intracoronary (IC) NIC administration (2mg/30s) during ATP infusion, FFR was measured again (NIC-FFR). To check cyclic change in FFR, we measured minimum and maximum FFR values during both ATP and NIC hyperemic phase. ResultsIn this study, 94 patients with 94 lesions were enrolled. Mean FFR value was 0.81±0.10 in ATP-FFR infusion and 0.80±0.09 in NIC-FFR, respectively. ATP-FFR and NIC-FFR had a strong correlation on the whole (r=0.92, p<0.001). In 18 patients (19%), FFR values were significantly lower in NIC-FFR than in ATP-FFR. In one-third of those patients (6%), it was possible to change therapeutic strategy from deferral range (>0.80) to interventional range (≦0.80) after NIC-FFR measurements. Cyclic change in FFR was smaller in NIC-FFR than in ATP-FFR (0.03±0.02 vs. 0.06±0.05, p<0.0001). ConclusionAdditional IC NIC might be useful to confirm sufficient maximum hyperemia after IV ATP infusion in daily clinical practice. Furthermore, IC NIC could reduce cyclic change in FFR; thus, physicians might find it easier to determine FFR value during the procedure.

Intracoronary administration of nicorandil during primary percutaneous coronary intervention: Impact on restoration of regional myocardial perfusion in reperfused myocardium during the subacute phase of myocardial infarction

BackgroundThe impact of nicorandil as adjunctive therapy for percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) is controversial. We performed 15O-labeled water positron emission tomography (PET) to quantify regional myocardial perfusion in patients with STEMI who received nicorandil or no adjunctive therapy during PCI. MethodsPCI was performed within 8h after STEMI onset in 33 patients. 14 patients received intracoronary nicorandil 2mg immediately after recanalization of the culprit lesion (Nico group). After 3–4weeks, PET was performed in which myocardial blood flow (MBF) was measured at baseline and during adenosine triphosphate (ATP)-induced hyperemia. Myocardial vascular resistance (MVR) was calculated for all segments. Data were obtained from the reperfused (Rep) and normal segments (Cont) in each patient. ResultsIn patients not given nicorandil (No-Nico group), the MBF was significantly lower in Rep than that in Cont at baseline and during hyperemia (Cont vs. Rep: 0.82±0.14 vs. 0.68±0.11, P=0.001, ATP-Cont vs. ATP-Rep: 2.00±0.72 vs. 1.52±0.61, P=0.017), which was restored in the Nico group (Cont vs. Rep: 0.79±0.17 vs. 0.78±0.20; ATP-Cont vs. ATP-Rep: 2.02±0.84 vs. 1.84±0.62). MVR was elevated in Rep at baseline and during hyperemia in the No-Nico group. MVR elevation in Rep was prevented in the Nico group. Conclusions15O-labeled water PET was feasible for segmental analysis of MBF during the subacute phase of STEMI. It revealed that intracoronary administration of nicorandil to STEMI patients who underwent PCI prevented MVR elevation and thus restored MBF in the reperfused segments to a level similar to that in the normal segments.

The effects of nicorandil on microvascular function in patients with ST segment elevation myocardial infarction undergoing primary PCI.

BackgroundNicorandil, as a selective potassium channel opener, has dual action including coronary and peripheral vasodilatation and cardioprotective effect through ischemic preconditioning. Considering those characteristics, nicorandil was suggested to reduce the degree of microvascular dysfunction.MethodsThirty-two patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI) were included in the study. Index of microvascular resistance (IMR) was measured in all patients immediatelly after pPCI before the after administration of Nicorandil. ST segment resolution was monitored before intervention and 60 min after terminating the procedure. Echocardiographic evaluation of myocardial function and transthoracic Doppler derived Coronary flow reserve (CFR) of infarct related artery (IRA) was performed during hospitalization and 3 months later.ResultsIMR was significantly lower after administration of Nicorandil (9.9 ± 3.7 vs. 14.1 ± 5.1, p < 0.001). There was significant difference in ST segment elevation before and after primary PCI with administration of Nicorandil (6.9 ± 3.7 mm vs. 1.6 ± 1.6 mm, p < 0.001). Transthoracic Doppler CFR measurement improved after 3 months (2.69 ± 0.38 vs. 2.92 ± 0.54, p = 0.021), as well as WMSI (1.14 ± 0.17 vs. 1.07 ± 0.09, p = 0.004).ConclusionIntracoronary Nicorandil administration after primary PCI significantly decreases IMR, resulting in improved CFR and ventricular function in patients with STEMI undergoing primary PCI.

A case of vasospastic angina in which the ergonovine provocation test with intracoronary isosorbide dinitrate and nicorandil was effective in the diagnosis of microvascular spasm

A 60-year-old man was admitted with early morning angina while at rest. Coronary angiogram revealed no organic lesions; therefore, a spasm provocation test with ergonovine was performed. Administration of intracoronary ergonovine induced total occlusion of the right coronary artery. The induced total occlusion improved but coronary flow velocity remained severely reduced and chest discomfort with ST-T changes in ECG remained in spite of repeated administration of isosorbide dinitrate (ISDN). Intracoronary administration of nicorandil following ISDN alleviated the chest discomfort, normalized the ST-T change in ECG, and improved the coronary flow. This suggested that microvascular spasm and the epicardial spasm were not relieved by ISDN but by nicorandil. Intracoronary nicorandil injection following ISDN administration may be useful for the diagnosis of microvascular spasm in the ergonovine provocation test.

Abstract 9608: Intracoronary Administration of Nicorandil During Direct Coronary Stenting Complements Restoration of Regional Perfusion at Subacute Phase of Myocardial Infarction: A Demonstration With O-15 Water Pet

Purpose: Controversies exist regarding the impact of nicorandil as the adjunctive therapy for direct coronary stenting in patients with ST elevation myocardial infarction (STEMI).Therefore, we performed O-15 water positron emission tomography (water PET) to quantify regional myocardial perfusion in patients with STEMI who received nicorandil or no adjunctive therapy during successful direct stenting. Methods: In 28 patients with STEMI (65+/-13 yrs: 22 males), direct stenting was performed within 8 hrs after the onset. Five of 28 patients who underwent successful direct stenting received intracoronary administration (i.c.) of nicorandil 4 mg immediately after the first recanalization of culprit lesion.At 3 to 4 weeks from the onset, water PET was performed in which myocardial blood flow (MBF) was measured at rest and during hyperemia and myocardial vascular esistance (MVR) was calculated. Data were obtained from both reperfused and normal control regions in each patient. Results: See Figure. In patients who did not receive nicorandil (No-Nico), MBF in reperfused area (Rep) was lower than that in normal control regions (Cont) both at rest and during hyperemia (ATP). However, in the nicorandil-treated patients, MBF in Rep was restored to the similar level of that in Cont both at rest and during ATP. MVR was elevated in Rep both at rest and during ATP in No-Nico patients; such elevation of MVR in Rep was successfully prevented in the nicorandil-treated patients. Conclusion: O-15 water-PET at subacute phase revealed that i.c.nicorandil during direct stenting successfully prevented the elevation of myocardial vascular resistance and thus, restored myocardial blood flow in reperfused areas to the similar level as that in non-infarcted regions in patients with STEMI.

Recurrence of Takotsubo cardiomyopathy with coronary slow flow phenomenon

This report presents the case of a 54-year-old female with Takotsubo cardiomyopathy that recurred 12 years after the first episode. The coronary angiography at the first admission revealed ergonovine-induced coronary vasoconstriction in the left coronary artery, and recurrence recurred after the interruption of vasodilator therapy to prevent vasospasm. In addition, the coronary angiography both in the first and second event demonstrated coronary slow flow phenomenon, which improved after the intracoronary administration of nicorandil. These findings indicate that coronary microvascular constriction plays an important role in the pathophysiology of Takotsubo cardiomyopathy.

No-Reflow Phenomenon During Treatment of Coronary In-Stent Restenosis With a Paclitaxel-Coated Balloon Catheter

Drug-eluting balloon (DEB) with angioplasty a paclitaxel-coated balloon catheter is an effective treatment option in patients with in-stent restenosis (ISR) after a drug-eluting stent (DES). We describe a case in which 'no-reflow' phenomenon developed after DEB angioplasty of a DES ISR lesion. Coronary flow was restored after intracoronary administration of nicorandil.

IMPACT OF SINGLE INTRACORONARY NICORANDIL ADMINISTRATION ON MICROCIRCULATORY DISTURBANCE AFTER SUCCESSFUL PRIMARY PERCUTANEOUS INTERVENTION IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

Background: Index of Microcirculatory Resistance (IMR) is an on-site parameter for the assessment of microcirculatory disturbance after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). High IMR has been shown to be a predictor of poor left ventricular (LV) function recovery. We sought to investigate the effects of intracoronary nicorandil administration after primary PCI on microvascular injury and chronic phase LV function.