Author + information
- Ashraf M. Al Azzoni,
- Pablo Lamelas,
- Tamara Marsden,
- Vladimir Dzavik,
- John Cairns,
- Brandi Meeks,
- Shamir Mehta,
- Madhu Natarajan,
- Tej Sheth,
- Jon-David Schwalm,
- Sunil Rao,
- Goran Stankovic,
- Sasko Kedev and
- Sanjit Jolly
Background: No-reflow during percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) has been previously associated with worse outcomes. The TOTAL trial showed that routine thrombus aspiration did not reduce the incidence of no-reflow. We sought to understand the predictors and associated outcomes of no-reflow during primary PCI.
Methods: TOTAL trial (N=10732 patients; 87 hospitals) was a randomized controlled trial of patients presenting with STEMI who were randomized to have their PCI with or without thrombectomy. We evaluated the patients whose PCI procedure was complicated with the no-reflow phenomenon and compared them with patients who did not experience no-reflow. Endpoints assessed were death, cardiogenic shock, and recurrent myocardial infarction at 1 year. Cox regression models were used to determine the association between no-reflow and endpoints.
Results: The no-reflow phenomenon complicated 267 out of 10064 (2.7%) primary PCI procedures in the trial. Out of the possible predictor variables assessed, only the following were found to predict the occurrence of no-reflow phenomenon: age (Odds Ratio [OR] 1.03 [95 % CI 1.02-1.04], P<0.0001), Killip class II-IV (OR 1.85 [95% CI 1.20-2.90], P=0.0058), initial TIMI 0/1 flow (OR 1.60 [95% CI 1.11-2.31], P=0.0123) and high thrombus burden (TIMI thrombus grade 3-5) (OR 2.15 [95% CI 1.13-4.10], P=0.0201). Thrombus aspiration, upstream GP IIb IIIa inhibitors, prophylactic adenosine or nitroprusside did not reduce the incidence of no reflow.
After adjustment for covariates, the occurrence of no-reflow was associated with worse outcomes including death (adjusted Hazard Ratio [HR] 1.90 [95% CI 1.33-2.71], P=0.0004), cardiogenic shock (HR 2.16 [95% CI 1.27-3.67], P=0.004) and recurrent myocardial infarction (HR 1.86 [95% CI 1.03-3.34], P=0.039).
Conclusions: In the contemporary era of rapid reperfusion for STEMI, no reflow is more likely to occur in patients with high thrombus burden and is still associated with marked increases in adverse outcomes. New treatments are needed to prevent and treat no reflow in patients with high thrombus burden.
Poster Hall, Hall C
Saturday, March 18, 2017, 9:45 a.m.-10:30 a.m.
Session Title: Novel Developments in Acute Coronary Syndromes
Abstract Category: 15. Interventional Cardiology: ACS/AMI/Hemodynamics and Pharmacology
Presentation Number: 1194-140
- 2017 American College of Cardiology Foundation