Author + information
- John R. Kapoor, MD, PhD and
- Roger Kapoor, MD, MBA⁎
- ↵⁎Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114
Early revascularization of the infarct-related artery by primary percutaneous coronary intervention has become the mainstay of therapy, especially in ST-segment elevation myocardial infarction. When performed early in the course of acute myocardial infarction, it has been shown to decrease mortality (1). However, in a number of patients undergoing primary percutaneous coronary intervention, epicardial coronary artery reperfusion does not translate into myocardial reperfusion, a phenomenon referred to as no-reflow. No-reflow has important clinical ramifications because it is associated with a worse prognosis (2). Niccoli et al. (2) discuss several investigated strategies for prevention and treatment of no-reflow, including management of distal embolization, reducing reperfusion times, and use of drugs such as glycoprotein IIb/IIIa antagonists. In this context, it is also clinically important to elaborate on the potential increased risk of no-reflow that is seen when deploying oversized stents. This notion was tested in 90 patients diagnosed with new ST-segment elevation (3). In this study, patients were divided into either the stent overexpansion group (n = 25 patients; stent-to-artery ratio >1.2) or the stent nonoverexpansion group (n = 65; stent-to-artery ratio <1.2). Notably, no-reflow was increased in the overexpansion group when compared with the nonoverexpansion group (32% vs. 11%, respectively, p = 0.031), and heart failure was seen more often (28% vs. 14%, respectively, p = 0.036), although there was less target lesion revascularization during follow-up in the overexpansion group (3). Thus, during coronary stenting, the risks of stent overexpansion should be weighed against the benefits to limit the potential for harm. Insofar as primary percutaneous coronary intervention has emerged as the preferred therapeutic method in ST-segment elevation myocardial infarctions, physicians should retain a heightened awareness of all clinically-relevant mechanisms implicated in the phenomenon of no-reflow, including overexpansion of coronary stents.
- American College of Cardiology Foundation