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3 Department of Anesthesia, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
4 Department of Cardiology, Himachal Heart Institute, Mandi, Himachal Pradesh, India
∗ Corresponding author: kunalmahajan442@gmail.com
Abstract. Epicardial coronary arteries are the subject of the majority of research attention and treatment techniques.
This is because interventional cardiologists focus on relieving the obstructions in epicardial coronary arteries which
are easily seen on angiography. On the contrary, the coronary microvasculature receives less attention. The heart
microvasculature, which consists of capillaries and arterioles, is negatively affected when the epicardial coronary
artery becomes blocked. When the occlusion is relieved, sometimes the blood flow to the ischemic tissue still remains
impeded, a phenomenon known as no-reflow. This review article aims to provide an in-depth understanding of the
pathophysiology and management strategies needed to tackle this life-threatening phenomenon.
Keywords: Coronary No-Reflow, Pathogenesis, Management.
INTRODUCTION for the management of NR. This makes it the need of the
hour to review this preventable catastrophic hurdle.
Ischemic heart disease is the leading cause of mor-
tality worldwide, accounting for 1.4 and 5.7 million
deaths in industrialized and developing countries, respec- INCIDENCE AND HISTORICAL REVIEW
tively, according to the Worldwide Burden of Disease
study [1]. Various modes of coronary intervention have Myocardial blush grade, TIMI flow grade, and ST resolu-
also increased to combat this looping surge. The recom- tion have all been used to estimate an incidence of 1% to 3%
mended strategy for percutaneous coronary intervention in large registries [3]. Cardiovascular magnetic resonance
(PCI) is used to treat acute myocardial infarction (AMI) [2]. imaging (CMRI) and myocardial contrast echocardiogra-
However, catheter-based interventions are associated with phy (MCE), which show a higher incidence (10–30%) of NR
numerous periprocedural complications. Coronary no- and microcirculatory dysfunction, are two more recent and
reflow (NR), a condition that results in suboptimal cardiac sensitive ways of diagnosing these conditions [2, 3].
reperfusion despite the infarct-related artery’s effective In 1974, Kloner et al. coined the term NR, which devel-
epicardial recanalization, with angiographic absence of oped following a brief epicardial coronary artery closure
dissection, spasm, obstruction, and thrombus, is the most for 90 min [3]. NR during primary percutaneous trans-
significant PCI-related complication. The phenomenon luminal coronary angioplasty (PTCA) for AMI was first
of NR has multifactorial pathogenesis and grave conse- observed by Feld et al. in 1992 [3]. Blood flow through
quences. There has been a paucity of clear-cut guidelines myocardial tissue at flow rates less than 40 mL/min/100 g
54
Coronary No-Reflow: Pathogenesis and Management 55
been described. There are studies that have demonstrated and resulted in a lower incidence of NR [3]. A recent
the role of induced hypothermia in the reduction of meta-analysis of 8 RCTs with 494 participants found that
myocardial infarct size. Herring et al. [3] demonstrated intracoronary verapamil + diltiazem injection is secure,
a marked reduction in NR with the use of induced and it considerably lowers NR when compared to the
hypothermia in animal models of myocardial infarction. control group (RR 0.3; p = 0.0002) [3]. Verapamil was
However, we do not have any human data on NR to linked to a lower frequency of angiographic MVO than
suggest the use of this induced hypothermia routinely sodium nitroprusside (SNP) (13.3 vs. 40%; p = 0.02), as
in MI patients. Moreover, there is a risk of prolonging well as a greater rate of STR 70% (33.3 vs. 6.7%; p = 0.01),
the door-to-balloon time. Second, few smaller trials have in a study comparing the two drugs’ impact on MVO in 60
suggested the use of ischemic post-conditioning to reduce patients with STEMI [2–4].
NR [3]. However, the lack of phase III trials and long-term
follow-up data limits its routine use in clinical practice. Nicorandil
each and every phase of PCI to avoid the complication [8] Carrick D, Oldroyd KG, McEntegart M, et al. A randomized trial of
of NR. deferred stenting versus immediate stenting to prevent no- or slow-
reflow in acute ST-segment elevation myocardial infarction (DEFER-
STEMI). J Am Coll Cardiol. 2014;63(20):2088–2098.
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