REstoration of COronary flow in patients with no-reflow after primary coronary interVEntion of acute myocaRdial infarction (RECOVER)

doi:10.1016/j.ahj.2012.06.015

American Heart Journal

Volume 164, Issue 3, September 2012, Pages 394-401

https://doi.org/10.1016/j.ahj.2012.06.015 Get rights and content

Background

No randomized trial has been conducted to compare different vasodilators for treating no-reflow during primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction.

Methods

The prospective, randomized, 2-center trial was designed to compare the effect of 3 different vasodilators on coronary no-reflow. A total of 102 patients with no-reflow in primary PCI were randomized to receive intracoronary infusion of diltiazem, verapamil, or nitroglycerin (n = 34 in each group) through selective microcatheter. The primary end point was coronary flow improvement in corrected thrombolysis in myocardial infarction frame count (CTFC) after administration of the drug.

Results

Compared with that of the nitroglycerin group, there was a significant improvement of CTFC after drug infusion in the diltiazem and verapamil groups (42.4 frames vs 28.1 and 28.4 frames, P < .001). The improvement in CTFC was similar between the diltiazem and verapamil groups (P = .9). Compared with the nitroglycerin group, the diltiazem and verapamil groups had more complete ST-segment resolution at 3 hours after PCI, lower peak troponin T level, and lower N-terminal pro–B-type natriuretic peptide levels at 1 and 30 days after PCI. After drug infusion, the drop of heart rate and systolic blood pressure in the verapamil group was greater than that in the diltiazem and nitroglycerin groups.

Conclusion

Intracoronary infusion of diltiazem or verapamil can reverse no-reflow more effectively than nitroglycerin during primary PCI for acute myocardial infarction. The efficacy of diltiazem and verapamil is similar, and diltiazem seems safer.

Section snippets

Patients

The RECOVER trial is a prospective, randomized, single-blinded, 2-center trial to compare the effect of 3 different vasodilators on coronary no-reflow in patients with ST-segment elevation AMI undergoing primary PCI. The study was conducted in 2 centers in Shanghai between December 2006 and March 2009. During this period, emergency primary PCI was performed in consecutive 608 patients who presented with ST-segment elevation AMI within 12 hours of symptom onset. The diagnosis was made on the

Baseline characteristics

There were no significant differences in the baseline clinical characteristics between the 3 groups (Table I). The mean reperfusion time in the 3 groups was similar, which was around 5 hours. Table II showed the lesion and procedural characteristics and the baseline flow poststenting in the 3 groups. There were no significant differences in the use of thrombus-aspiration device and intravenous/intracoronary glycoprotein IIb/IIIa inhibitor. The coronary flow after stenting or before drug

Discussion

Our study is the first randomized trial to compare different vasodilators for treating no-reflow during primary PCI in patients with ST-segment elevation AMI. In our study, the incidence of no-reflow after primary PCI was 17%, which was consistent with previously published no-reflow rates of around 5% to 29% in AMI mechanical reperfusion.13, 14, 15 There were some procedural characteristics in our study that might affect the occurrence of no-reflow phenomenon. First, the overall use of manual

Disclosures

None.

Acknowledgements

We would like to thank Kai Hu, MD, University of Würzburg, for the help in data collection and manuscript revision.

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Cited by (47)

Advances in our Understanding and Treatment of the No-Reflow Phenomenon After PCI for STEMI
2022, Cardiovascular Revascularization Medicine
Our enemy: the clot. Coronary thrombosis: strategy and therapeutic arsenal
2021, Annales de Cardiologie et d'Angeiologie
La présence d'un thrombus coronaire ou sa majoration est fréquente lors de la revascularisation des patients ayant un syndrome coronarien aigu en particulier en cas d'infarctus du myocarde avec sus décalage du segment ST. Ce phénomène complique plus rarement l'angioplastie coronaire réalisée pour un angor stable. Dans ces deux présentations c'est un facteur de risque de mauvais résultat angiographique et de mauvais pronostic. Le thrombus coronaire peut être à l'origine d'une occlusion coronaire per procédure ou d'une perfusion distale altérée par micro embols distaux. Le traitement préventif de cette complication repose sur le respect d'un traitement anti thrombotique optimal et le choix parfois pertinent de revascularisation différée après mise en évidence de lésions angiographiquement complexes. Le traitement curatif en reste controversé avec une évolution des recommandations concernant les modalités de revascularisation comme l'usage de la thrombectomie. Cette dernière garde une place dans l'arsenal thérapeutique du cardiologue interventionnel de même que les inhibiteurs de la glycoprotéine IIb IIIa. L'existence d'un phénomène de no-reflow est une complication complexe de la revascularisation en partie mais non uniquement en rapport avec un phénomène thrombotique. Son traitement en reste imprécis faute d’études déterminantes. En raison de son mauvais pronostic les moyens thérapeutiques mécaniques et pharmacologiques actuellement à notre disposition doivent être connus et utilisés selon le contexte clinique et la présentation angiographique, dans l'attente de nouvelles avancées thérapeutiques.
Intra coronary thrombus is frequently encountered during acute coronary syndromes revascularisation procedures. It can also be encountered during angioplasty procedures in a stable angina context, although at a much lesser frequency.In both situations, it harbors a risk of poor angiographic result and poor prognosis. Intracoronnary thrombus may cause coronary occlusion at the angioplasty site or distal embolic flow obstruction. Per procedure thrombus prevention rests on an prior optimal anti thrombotic treatment and in some circumstances the choice to defer the revascularisation procedure in the complex high risk setting. Treating the initiated thrombus remains controversial concerning thrombectomy and GPIIBIIIa inhibitors which are still in use in common practice. No reflow phenomenon is a particularly complex setting during cornary angioplasties, partially but not solely related to a thrombotic complication. It's treatment remains unclear in the absence of related oriented studies.The current mechanical and pharmacological antithrombotic therapies must remain common practice and used appropriately as of the clinical and angiographic setting, until further scientific outbrakes.
Effect of GP IIb/IIIa inhibitor duration on the clinical prognosis of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction with no-/slow-reflow phenomenon
2021, Biomedicine and Pharmacotherapy
Citation Excerpt :
Achieving adequate epicardial coronary blood flow during pPCI is critical. Currently, the treatment of no-/slow-reflow includes both pharmacological [4–8] and non-pharmacological therapies [9]. Only a small number of drugs have shown benefit in the treatment of no-/slow-reflow; among them, tirofiban, a widely used GP IIb/IIIa inhibitor (GPI), is recommended as a bail-out therapy for cases with no-/slow-reflow during pPCI [10–14].
In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) accompanied by the no-/slow-reflow phenomenon, the maintenance duration of GP IIb/IIIa inhibitor (GPI) is controversial. We compare the efficacy and safety of short- and long-term GPI infusion in STEMI patients with the no-/slow-reflow phenomenon.
From June 2016 to December 2019, we continuously included patients with on-set STEMI who underwent pPCI, accompanied by the no-/slow-reflow, during interventional procedures at Guangdong Provincial People’s Hospital and Zhuhai Golden Bay Hospital. The hemorrhage events, heart function, and major adverse cardiovascular events (MACE) were compared between < 24 h and ≥ 24 h GPI duration groups. The Kaplan–Meier curve was used to estimate the 1-year MACE-free survival at different GPI utility times.
In total, 127 patients were divided into two groups based on the duration of tirofiban use (less and more than 24 h). There was no significant difference between two groups in terms of baseline characteristics, plaque condition, and coronary physiological function. The two groups showed similar in-hospital MACE (1 [1.85%] vs. 4 [5.48%], p = 0.394) and 1-year MACE-free survival (log-rank test p = 0.9085). The 1-year MACE remained consistent between the two groups in all subgroups of different risk factors of no-/slow-reflow. There was no significant difference in heart function and in-hospital hemorrhage events (3.7% vs. 1.37%, p = 0.179).
In the real world, prolonging the duration of GPI may not significantly improve the clinical outcome in patients with STEMI with no-/slow-reflow.
Myocardial preservation during primary percutaneous intervention: It's time to rethink?
2021, Indian Heart Journal
Large intracoronary thrombus and its management during primary PCI
2020, Indian Heart Journal
Citation Excerpt :
Intracoronary calcium channel blockers predominantly dilate the small resistance arterioles but may also inhibit platelet aggregation in the microvasculature. In RECOVER trial,33 a total of 102 patients with no-reflow in primary PCI were randomized to receive intracoronary infusion of diltiazem, verapamil, or nitroglycerin (n = 34 in each group) through selective microcatheter. Compared with nitroglycerin group, there was a significant improvement in corrected TIMI frame count (CTFC) after drug infusion in the diltiazem and verapamil groups.
Large intracoronary thrombus has been reported in significant number of patients with STEMI. Primary PCI is the current standard of care in patients of STEMI. Despite the availability of dual antiplatelets, GP IIb/IIIa inhibitor and effective anticoagulation regimens, large intracoronary thrombus remains one of the biggest challenge to interventional cardiologists during primary PCI. Large intracoronary thrombus may lead to distal embolization, no/slow reflow or embolization into a non-culprit vessel and is associated with adverse cardiovascular outcome. There is no ideal management strategy. We hereby discuss the current available methods/strategies to deal with large thrombus burden encountered during primary PCI, in the current manuscript.
Intracoronary infusion of alprostadil and nitroglycerin with targeted perfusion microcatheter in STEMI patients with coronary slow flow phenomenon
2018, International Journal of Cardiology
Citation Excerpt :
Along guidewire, targeted perfusion microcatheter can reach the distal part of the angioplasty site and directly release drug into vessels where the blood flow is slow. This technology can maintain a high drug concentration in local coronary arteries as well as a low systemic concentration, which furtherly ensures the safety of alprostadil administration [14]. Although changes of coronary flow finding and complete STR in this study implied that compared with nitroglycerin, alprostadil might be more effective in alleviating CSFP.
The treating aims of ST-segment elevation myocardial infarction (STEMI) are vessels recanalization and coronary flow restoration. Coronary slow flow phenomenon (CSFP) is one of the common complications in STEMI patients after percutaneous coronary intervention (PCI) and leads to a higher incidence of adverse clinical outcomes. Alprostadil is a kind of liposomal prostaglandin E1 with beneficial effects on vasodilation, platelet disaggregation and fibrinolysis. But it still remains unclear that whether alprostadil can improve the coronary perfusion in STEMI patients with CSFP after PCI.
In this study, a total of 57 STEMI cases with CSFP were included, 28 of which received 2 μg alprostadil by intracoronary infusion with targeted perfusion microcatheter while the others received 200 μg nitroglycerin. Coronary angiograms were analyzed by two experienced interventional cardiologists who were blinded to the medicine administration.
We found that compared with nitroglycerin, alprostadil treatment was significantly more effective in increasing the incidence of TFG 3(78.6% vs. 48.3%, P = 0.021), MBG 3(46.4% vs. 20.7%, P = 0.039), TMPG 3(53.6% vs. 24.1%, P = 0.022) and complete STR (42.8% vs. 17.2%, P = 0.035) and reducing cTFC (28.71 frames vs. 46.03 frames, P = 0.001). Furthermore, in this study, intracoronary infusion of alprostadil with targeted perfusion microcatheter hardly affected the blood pressure and heart rate of patients, and no threaten complication were observed.
Alprostadil can effectively alleviate CSFP, which is at the same time secure even for STEMI patients.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT03296670

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Clinical InvestigationInterventional CardiologyREstoration of COronary flow in patients with no-reflow after primary coronary interVEntion of acute myocaRdial infarction (RECOVER)

Background

Methods

Results

Conclusion

Section snippets

Patients

Baseline characteristics

Discussion

Disclosures

Acknowledgements

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

No-reflow: the next challenge in treatment of ST-elevation acute myocardial infarction

Eur Heart J

Treatment of no-reflow in degenerated saphenous vein graft interventions: comparison of intracoronary verapamil and nitroglycerin

Cathet Cardiovasc Diagn

Pretreatment with intragraft verapamil prior to percutaneous coronary intervention of saphenous vein graft lesions: results of the randomized, controlled vasodilator prevention on no reflow (VAPOR) trial

J Invasive Cardiol

Intracoronary verapamil for reversal of no-reflow during coronary angioplasty for acute myocardial infarction

Catheter Cardiovasc Interv

Clinical Investigation
Interventional Cardiology
REstoration of COronary flow in patients with no-reflow after primary coronary interVEntion of acute myocaRdial infarction (RECOVER)