Coronary microvascular obstruction (the no-reflow phenomenon) during percutaneous coronary interventions in patients with myocardial infarction
Published 2020-04-07
Keywords
- coronary microvascular obstruction,
- no-reflow,
- myocardial infarction with ST segment elevation,
- reperfusion injury
How to Cite
Copyright (c) 2020 Frolov A. A., Pochinka I. G., Shahov B. E., Sharabrin E. G., Kuzymichev K. V.

This work is licensed under a Creative Commons Attribution 4.0 International License.
Abstract
Coronary microvascular obstruction (the no-reflow phenomenon) after percutaneous coronary interventions in diagnosed with myocardial infarction has a significant negative impact on both the short-term and long-term prognosis. The mechanisms underlying this disorder are heterogeneous and complex, and as such it is difficult to devise effective treatments and/or to predict specific outcomes. Modern therapeutic approaches have indirect cardioprotective effects and certainly reduce the risk of no-reflow. However, attempts to create a drug or method that fundamentally improve the prognosis in patients with coronary microvascular obstruction have been unsuccessful. Thus, the problem of myocardial reperfusion damage has not been solved and further study will be necessary to provide support for the search for new therapeutic modalities. The purpose of this review is to provide an analysis of relevant literature that focuses on the aetiology, pathogenesis, diagnosis, prognosis and treatment of the coronary microvascular obstruction during and after percutaneous coronary interventions in patients diagnosed with myocardial infarction. We searched using the Medline (PubMed), RSCI (eLIBRARY), Embase and Google Scholar databases for all relevant literature pertaining to this subject.
Received 13 January 2020. Accepted 11 February 2020.
Funding: The study did not have sponsorship.
Conflict of interest: Authors declare no conflict of interest.
References
- Ibanez B., James S., Agewall S., Antunes M.J., Bucciarelli-Ducci C., Bueno H., Caforio A.L.P., Crea F., Goudevenos J.A., Halvorsen S., Hindricks G., Kastrati A., Lenzen M.J., Prescott E., Roffi M., Valgimigli M., Varenhorst C., Vranckx P., Widimský P. ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2017;39(2):119-77. PMID: 28886621. http://doi.org/10.1093/eurheartj/ehx393
- Gupta S., Gupta M.M. No reflow phenomenon in percutaneous coronary interventions in ST-segment elevation myocardial infarction. Indian Heart J. 2016;68(4):539-51. PMID: 27543480. http://doi.org/10.1016/j.ihj.2016.04.006
- Kloner R.A., Ganote C.E., Jennings R.B. The “no-reflow” phenomenon after temporary coronary occlusion in the dog. J Clin Invest. 1974;(54):1496-508. PMID: 4140198. http://doi.org/10.1172/jci107898
- Гречишкин А.А., Майнгарт С.В., Пахолков А.Н. Актуальность проблемы реперфузионного повреждения миокарда при первичном чрескожном коронарном вмешательстве. Эндоваскулярная хирургия. 2015;2(1):21-31. [Grechishkin A.A., Mayngart S.V., Pakholkov A.N. The urgency of myocardial reperfusion injury in primary percutaneous coronary intervention. Endovaskulyarnaya khirurgiya = Endovascular surgery. 2015;2(1):21-31. (In Russ.)]
- Mueller H.S., Dyer A., Greenberg M.A., The TIMI Study Group. The Thrombolysis In Myocardial Infarction (TIMI) trial. Phase I findings. N Engl J Med. 1985;312(14):932-36. PMID: 4038784. http://doi.org/10.1056/nejm198504043121437
- van ‘t Hof A.W., Liem A., Suryapranata H., Hoorntje J.C., de Boer M.J., Zijlstra F. Zwolle Myocardial Infarction Study Group. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: myocardial blush grade. Circulation. 1998;97(23):2302-6. PMID: 9639373. http://doi.org/10.1161/01.cir.97.23.2302
- Niccoli G., Scalone G., Lerman A., Crea F. Coronary microvascular obstruction in acute myocardial infarction. Eur Heart J. 2016;37(13):1024-33. PMID: 26364289. http://doi.org/10.1093/eurheartj/ehv484
- Bouleti C., Mewton N., Germain S.. The no-reflow phenomenon: State of the art. Arch Cardiovasc Dis. 2015;108(12):661-74. PMID: 26616729. http://doi.org/10.1016/j.acvd.2015.09.006
- de Waha S., Patel M.R., Granger C.B., Ohman E.M., Maehara A., Eitel I., Ben-Yehuda O., Jenkins P., Thiele H., Stone G.W. Relationship between microvascular obstruction and adverse events following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: an individual patient data pooled analysis from seven randomized trials. Eur Heart J. 2017;38(47):3502-10. PMID: 29020248. http://doi.org/10.1093/eurheartj/ehx414
- Durante A., Camici P.G. Novel insights into an “old” phe-nomenon: the no reflow. Int J Cardiol. 2015;187:273-80. PMID: 25838230. http://doi.org/10.1016/j.ijcard.2015.03.359
- Ягудин Т.А., Шабанова А.Т., Лиу Х.Ю. Новые аспекты в механизмах ишемического и реперфузионного повреждения миокарда. Креативная хирургия и онкология. 2018;8(3):216-24. http://doi.org/10.24060/2076-3093-2018-8-3-216-224 [Yagudin T.A., Shabanova A.T., Liu H. Novel aspects of cardiac ischemia and reperfusion injury mechanisms. Creative surgery and oncology. 2018;8(3):216-24. http://doi.org/10.24060/2076-3093-2018-8-3-216-224 (In Russ.)]
- Mangold A., Alias S., Scherz T., Hofbauer T., Jakowitsch J., Panzenbock A., Simon D., Laimer D., Bangert C., Kammerlander A., Mascherbauer J., Winter M.P., Distelmaier K., Adlbrecht C., Preissner K.T., Lang I.M. Coronary neutrophil extracellular trap burden and deoxyribonuclease activity in ST-elevation acute coronary syndrome are predictors of ST-segment resolution and infarct size. Circ Res. 2015;116(7):1182-92. PMID: 25547404. http://doi.org/10.1161/circresaha.116.304944
- Wu M.Y., Yiang G.T., Liao W.T., Tsai A.P., Cheng Y.L., Cheng P.W., Li C.Y., Li C.J. Current Mechanistic Concepts in Ischemia and Reperfusion Injury. Cell Physiol Biochem. 2018;46(4):1650-67. PMID: 29694958. http://doi.org/10.1159/000489241
- Amier R.P., Tijssen R.Y.G., Teunissen P.F.A., Fernandez-Jimenez R., Pizarro G., Garcia-Lunar I., Bastante T., van de Ven P.M., Beek A.M., Smulders M.W., Bekkers S.C.A.M., van Royen N., Ibanez B., Nijveldt R. Predictors of intramyocardial hemorrhage after reperfused st-segment elevation myocardial infarction. J Am Heart Assoc. 2017;6(8):e005651. PMID: 28862937. http://doi.org/10.1161/jaha.117.005651
- Niccoli G., Montone R.A., Ibanez B., Thiele H., Crea F., Heusch G., Bulluck H., Hausenloy D.J., Berry C., Stiermaier T., Camici P.G., Eitel I. Optimized treatment of ST-elevation myocardial infarction. The unmet need to target coronary microvascular obstruction as primary treatment goal to further improve prognosis. Circ Res. 2019;125(2):245-58. PMID: 31268854. http://doi.org/10.1161/circresaha.119.315344
- Corban M.T., Lerman L.O., Lerman A. Ubiquitous yet unseen: microvascular endothelial dysfunction beyond the heart. Eur Heart J. 2018;39(46):4098-100. PMID: 30165379. http://doi.org/10.1093/eurheartj/ehy576
- Wang J.W., Zhou Z.Q., Chen Y.D., Wang C.H., Zhu X.L. A risk score for no reflow in patients with ST-segment elevation myocardial infarction after percutaneous coronary intervention. Clin Cardiol. 2015;38(4):208-15. PMID: 25892404. http://doi.org/10.1002/clc.22376
- Gibson C.M., de Lemos J.A., Murphy S.A., Marble S.J., McCabe C.H., Cannon C.P., Antman E.M., Braunwald E., TIMI Study Group. Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction: a TIMI 14 substudy. Circulation. 2001;103(21):2550-4. PMID: 11382722. http://doi.org/10.1161/01.cir.103.21.2550
- Rentrop K.P., Cohen M., Blanke H., Phillips R.A. Changes in collateral filling after controlled coronary artery occlusion by an angioplasty balloon in human subjects. J Am Coll Cardiol. 1985;5(3):587-92. PMID: 3156171. http://doi.org/10.1016/s0735-1097(85)80380-6
- Fajara J.K., Heriansyahc T., Rohmand M.S. The predictors of no reflow phenomenon after percutaneous coronary intervention in patients with ST elevation myocardial infarction: A meta-analysis. Indian Heart J. 2018;70:s406-18. PMID: 30595300. http://doi.org/10.1016/j.ihj.2018.01.032
- Mazhar J., Mashicharana M., Farshid A. Predictors and outcome of no-reflow post primary percutaneous coronary intervention for ST elevation myocardial infarction. Int J Cardiol Heart Vasc. 2016;10:8-12. PMID: 28616509. http://doi.org/10.1016/j.ijcha.2015.11.002
- Parviz Y., Vijayan S., Lavi S. A review of strategies for infarct size reduction during acute myocardial infarction. Cardiovasc Revasc Med. 2017;18(5):374-83. PMID: 28214140. http://doi.org/10.1016/j.carrev.2017.02.004
- Soeda T., Higuma T., Abe N., Yamada M., Yokoyama H., Shibutani S., Ong D.S., Vergallo R., Minami Y., Lee H., Okumura K., Jang I.K. Morphological predictors for no reflow phenomenon after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction caused by plaque rupture. Eur Heart J Cardiovasc Imaging. 2017;(1):103-10. PMID: 26800769. http://doi.org/10.1093/ehjci/jev341
- Rezkalla S.H., Stankowski R.V., Hanna J., Kloner R.A. Management of no-reflow phenomenon in the catheterization laboratory. JACC Cardiovasc Interv. 2017;10(3):215-23. PMID: 28183461. http://doi.org/10.1016/j.jcin.2016.11.059
- Garcia-Mendez R.C., Almeida-Gutierrez E., Serrano-Cuevas L., Sanchez-Diaz J.S., Rosas-Peralta M., Ortega-Ramirez J.A., Palomo-Villada J.A., Isordia-Salas I., Alonso-Bravo R.M., Borrayo-Sanchez G. Reduction of no reflow with a loading dose of atorvastatin before primary angioplasty in patients with acute ST myocardial infarction. Arch Med Res. 2018;49(8):620-9. PMID: 30446246. http://doi.org/10.1016/j.arcmed.2018.10.006
- Roolvink V., Ottervanger J.P., Ibanez B., Dambrink J.H., Gosselink M., Kedhi E., van Royen N., Lipsic E., Remkes W., Piek J., Fuster V., van ‘t Hof A. One-year clinical outcome of early administration of intravenous beta-blockers in patients with ST-segment elevation myocardial infarction before primary percutaneous coronary reperfusion. EuroIntervention. 2018;14(6):688-91. PMID: 29155386. http://doi.org/10.4244/eij-d-17-00776
- Selker H.P., Harris W.S., Rackley C.E., Marsh J.B., Ruthazer R., Beshansky J.R., Rashba E.J., Peter I., Opie L.H. Very early administration of glucose-insulin-potassium by emergency medical service for acute coronary syndromes: Biological mechanisms for benefit in the IMMEDIATE Trial. Am Heart J. 2016;178:168-75. PMID: 27502865. http://doi.org/10.1016/j.ahj.2016.03.026
- Noc M., Erlinge D., Neskovic A.N., Kafedzic S., Merkely B., Zima E., Fister M., Petrovic M., Cankovic M., Veress G., Laanmets P., Pern T., Vukcevic V., Dedovic V., Sredniawa B., Swiatkowski A., Keeble T.R., Davies J.R., Warenits A.M., Olivecrona G., Peruga J.Z., Ciszewski M., Horvath I., Edes I., Nagy G.G., Aradi D., Holzer M. COOL AMI EU pilot trial: a multicentre, prospective, randomised controlled trial to assess cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction. EuroIntervention. 2017;13(5):e531-9. PMID: 28506940. http://doi.org/10.4244/eij-d-17-00279
- Elbadawi A., Ha L.D., Abuzaid A.S., Crimi G., Azzouz M.S. Meta-analysis of randomized trials on remote ischemic conditioning during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. Am J Cardiol. 2017;119(6):832-8. PMID: 28065491. http://doi.org/10.1016/j.amjcard.2016.11.036
- Hausenloy D.J., Kharbanda R.K., Moller U.K., Ramlall M., Aaroe J., Butler R., Bulluck H., Clayton T., Dana A., Dodd M., Engstrom T., Evans R., Lassen J.F., Christensen E.F., Garcia-Ruiz J.M., Gorog D.A., Hjort J., Houghton R.F., Ibanez B., Knight R., Lippert F.K., Lonborg J.T., Maeng M., Milasinovic D., More R., Nicholas J.M., Jensen L.O., Perkins A., Radovanovic N., Rakhit R.D., Ravkilde J., Ryding A.D., Schmidt M.R., Riddervold I.S., Sorensen H.T., Stankovic G., Varma M., Webb I., Terkelsen C.J., Greenwood J.P., Yellon D.M., Botker H.E., CONDI-2/ERIC-PPCI Investigators. Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial. Lancet. 2019;394(10207):1415-24. PMID: 31500849. http://doi.org/10.1016/s0140-6736(19)32039-2
- Jolly S.S., Cairns J.A., Yusuf S., Rokoss M.J., Gao P., Meeks B., Kedev S., Stankovic G., Moreno R., Gershlick A., Chowdhary S., Lavi S., Niemela K., Bernat I., Cantor W.J., Cheema A.N., Steg P.G., Welsh R.C., Sheth T., Bertrand O.F., Avezum A., Bhindi R., Natarajan M.K., Horak D., Leung R.C., Kassam S., Rao S.V., El-Omar M., Mehta S.R., Velianou J.L., Pancholy S., Dzavik V., TOTAL Investigators. Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1-year follow-up of the prospective randomised TOTAL trial. Lancet. 2016;387(10014):127-35. PMID: 26474811. http://doi.org/10.1016/S0140-6736(15)00448-1
- Neumann F.J., Gick M. Direct stenting in ST-elevation myocardials infarction: convenient, but not improving outcomes. Eur Heart J. 2018;39(26):2480-3. PMID: 29931300. http://doi.org/10.1093/eurheartj/ehy353
- De Maria G.L., Alkhalil M., Oikonomou E.K., Wolfrum M., Choudhury R.P., Banning A.P. Role of deferred stenting in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention: A systematic review and meta-analysis. Interv Cardiol. 2017;30(3):264-73. PMID: 28370496. http://doi.org/10.1111/joic.12380
- Nepper-Christensen L., Hofsten D.E., Helqvist S., Lassen J.F., Tilsted H.H., Holmvang L., Pedersen F., Joshi F., Sorensen R., Bang L., Botker H.E., Terkelsen C.J., Maeng M., Jensen L.O., Aaroe J., Kelbaek H., Kober L., Engstrom T., Lonborg J. Interaction of ischaemic postconditioning and thrombectomy in patients with ST-elevation myocardial infarction. Heart. 2019;106(1):1-9. PMID: 31315939. http://doi.org/10.1136/heartjnl-2019-314952
- Lonborg J.T. Targeting reperfusion injury in the era of primary percutaneous coronary intervention: hope or hype? Heart. 2015;101(20):1612-8. PMID: 26130664. http://doi.org/10.1136/heartjnl-2015-307804
- Hausenloy D.J., Botker H.E., Engstrom T., Erlinge D., Heusch G., Ibanez B., Kloner R.A., Ovize M., Yellon D.M., Garcia-Dorado D. Targeting reperfusion injury in patients with ST-segment elevation myocardial infarction: trials and tribulations. Eur Heart J. 2017;38(13):935-41. PMID: 27118196. http://doi.org/10.1093/eurheartj/ehw145
- Jones D.A., Pellaton C., Velmurugan S., Rathod K.S., Andiapen M., Antoniou S., van Eijl S., Webb A.J., Westwood M.A., Parmar M.K., Mathur A., Ahluwalia A. Randomized phase 2 trial of intracoronary nitrite during acute myocardial infarction. Circ Res. 2015;116(3):437-47. PMID: 25512434. http://doi.org/10.1161/circresaha.116.305082
- Wang L., Cheng Z., Gu Y., Peng D. Short-term effects of verapamil and diltiazem in the treatment of no reflow phenomenon: a meta-analysis of randomized controlled trials. Biomed Res Int. 2015;(2015):382086. PMID: 26504804. http://doi.org/10.1155/2015/382086
- Bulluck H., Sirker A., Loke Y.K., Garcia-Dorado D., Hausenloy D.J. Clinical benefit of adenosine as an adjunct to reperfusion in ST-elevation myocardial infarction patients: an updated meta-analysis of randomized controlled trials. Int J Cardiol. 2015;202:228-37. PMID: 26402450. http://doi.org/10.1016/j.ijcard.2015.09.005
- Шахов Б.Е., Шахов Е.Б., Петрова Е.Б., Шарабрин Е.Г., Чеботарь Е.В. Случай успешного применения чрескожной временной окклюзии венозного синуса сердца у больного с острым коронарным синдромом с элевацией сегмента ST при отсутствии гемодинамически значимого атеросклеротического поражения коронарных артерий. Креативная хирургия и онкология. 2017;7(1):48-53. https://doi.org/10.24060/2076-3093-2017-7-1-48-53 [Shakhov B.E., Shakhov E.B., Petrova E.B., Sharabrin E.G., Chebotar Y.V. A case of successful use of percutaneous temporary occlusion of the heart venous sinus in patient with acute coronary syndrome with ST segment elevation in the absence of hemodynamically significant atherosclerotic lesions of the coronary arteries. Creative Surgery and Oncology. 2017;7(1):48-53. https://doi.org/10.24060/2076-3093-2017-7-1-48-53 (In Russ.)]
- Jolly S.S., Cairns J.A., Yusuf S., Meeks B., Pogue J., Rokoss M.J., Kedev S., Thabane L., Stankovic G., Moreno R., Gershlick A., Chowdhary S., Lavi S., Niemelä K., Steg P.G., Bernat I., Xu Y., Cantor W.J., Overgaard C.B., Naber C.K., Cheema A.N., Welsh R.C., Bertrand O.F., Avezum A., Bhindi R., Pancholy S., Rao S.V., Natarajan M.K., ten Berg J.M., Shestakovska O., Gao P., Widimsky P., Dzavik V., TOTAL Investigators. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015;372(14):1389-98. PMID: 25853743. http://doi.org/10.1056/NEJMoa1415098
- Jang H.J., Park S.D., Park H.W., Suh J., Oh P.C., Moon J., Lee K., Kang W.C., Kwon S.W., Kim T.H. Outcome of triple antiplatelet therapy including cilostazol in elderly patients with ST-elevation myocardial infarction who underwent primary percutaneous coronary intervention: results from the INTERSTELLAR Registry. Drugs Aging. 2017;34(6):467-77. PMID: 28456945. http://doi.org/10.1007/s40266-017-0463-9
- Gyongyosi M., Wojakowski W., Lemarchand P., Lunde K., Tendera M., Bartunek J., Marban E., Assmus B., Henry T.D., Traverse J.H., Moye L.A., Surder D., Corti R., Huikuri H., Miettinen J., Wohrle J., Obradovic S., Roncalli J., Malliaras K., Pokushalov E., Romanov A., Kastrup J., Bergmann MW., Atsma D.E., Diederichsen A., Edes I., Benedek I., Benedek T., Pejkov H., Nyolczas N., Pavo N., Bergler-Klein J., Pavo I.J., Sylven C., Berti S., Navarese E.P., Maurer G., ACCRUE Investigators. Meta-analysis of cell-based cardiac studies (ACCRUE) in patients with acute myocardial infarction based on individual patient data. Circ Res. 2015;116(8):1346-60. PMID: 25700037. http://doi.org/10.1161/circresaha.116.304346
