Comparison of Intracoronary Epinephrine and Adenosine for No-Reflow in Normotensive Patients With Acute Coronary Syndrome (COAR Trial)

Background: Intracoronary epinephrine has been effectively used in treating refractory no-reflow, but there is a dearth of data on its use as a first-line drug in normotensive patients in comparison to the widely used adenosine. Methods: In this open-labeled randomized clinical trial, 201 patients with no-reflow were randomized 1:1 into intracoronary epinephrine as the treatment group and intracoronary adenosine as the control group and followed for 1 month. The primary end points were improvement in coronary flow, as assessed by TIMI (Thrombolysis in Myocardial Infarction) flow, frame counts, and myocardial blush. Secondary end points were in-hospital and short-term mortality and major adverse cardiac events. Results: In all, 101 patients received intracoronary epinephrine and 100 patients received adenosine. Epinephrine was generally well tolerated with no immediate table death or ventricular fibrillation. No-reflow was more effectively improved with epinephrine with final TIMI III flow (90.1% versus 78%, P =0.019) and final corrected TIMI frame count (24±8.43 versus 26.63±9.22, P =0.036). However, no significant difference was observed in final grade III myocardial blush (55.4% versus 45%, P =0.139), mean reduction of corrected TIMI frame count (−25.71±11.79 versus −26.08±11.71, P =0.825), in-hospital and short-term mortality, and major adverse cardiac events. Conclusions: Epinephrine is relatively safe to use in no-reflow in normotensive patients. A significantly higher frequency of post-treatment TIMI III flow grade and lower final corrected TIMI frame count with relatively better achievement of myocardial blush grade III translate into it displaying relatively better efficacy than adenosine. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04699110.

Plasma atherogenic indices are independent predictors of slow coronary flow

Background Although the pathophysiology of coronary slow flow (CSF) has not been fully elucidated, emerging data increasingly support potential role for subclinical diffuse atherosclerosis in the etiology of CSF. We aimed to investigate relationship between atherogenic indices and CSF. Methods 130 patients with CSF diagnosed according to Thrombolysis in Myocardial Infarction (TIMI)-frame count (TFC) method and 130 controls who had normal coronary flow (NCF) were included in this retrospective study. Atherogenic indices (atherogenic index of plasma [AIP], Castelli risk indices I and II [CRI-I and II]) were calculated using conventional lipid parameters. Results The logistic regression analyses demonstrated that AIP (OR, 5.463; 95% confidence interval [CI], 1.357–21.991; p = 0.017) and CRI-II (OR, 1.624; 95% CI, 1.138–2.319; p = 0.008) were independent predictors of CSF. Receiver operating characteristic analysis showed that the optimal cutoff value to predict the occurrence of CSF was 0.66 for AIP (sensitivity, 59%; specificity, 73%; area under curve [AUC], 0.695; p < 0.001) and 3.27 for CRI-II (sensitivity, 60%; specificity, 79%; AUC, 0.726; p < 0.001). Conclusions AIP and CRI-II levels were independent predictors of CSF. Prospective studies in larger cohorts of patients may elucidate the role of atherogenic dyslipidemia in the pathophysiology of CSF.

293 Impact of metabolic syndrome on coronary microvascular dysfunction: a single-centre experience

Aims The purpose of this study was to evaluate whether microvascular dysfunction is more present in patients with metabolic syndrome (MetS) compared to diabetics and hypertensive patients with two angiographic imaging methods, to evaluate the degree of microcirculation dysfunction, the TIMI frame count and Myocardial Blush grade. Both techniques of rapid use and relatively cheap, and allow us to have a good degree of evaluation referred to the function of the coronary microcirculation. Methods and results The study included 445 patients allocated into three groups, 157 in the MetS group, 128 in the diabetics group, and 160 patients in the hypertensive group. All patients accessed to the emergency room for anginal chest pain, all were hospitalized in the cardiac intensive care unit from 2015 to 2020. Inclusion criteria were the presences of chest pain and/or their positive stress test, and epicardial coronary arteries free from stenosis at coronary angiography. We compared the results obtained from the angiographic techniques (TIMI Frame Count and Myocardial Blush Grade) in the two subgroups: MetS vs. hypertensive, and MetS vs. diabetics. In the first subgroup, we analyzed the TFCs of the three vessels in patients with hypertension and comparing them with patients with MetS, we observed that the latter have a worse perfusion condition: the three epicardial coronary vessels have a higher TFC than the hypertensive population (TFC LAD 33.1 ± 5.6 vs. 28.4 ± 5.6, P = 0.018), (TFC RCA 27.2 ± 5.2 vs. 23.1 ± 5.2, P = 0.014) (TFC CX 27.9 ± 5.4 vs. 26.9 ± 5.4, P = 0.03). That indicates slow flow in patients with MetS coronary microcirculation. Analyzing the MBG, however, in the three coronary vessels of patients with hypertension compared to patients with metabolic syndrome, no difference was found in terms of worsening of the coronary microcirculation. Finally comparing the indices that summarize the values of the individual arteries both for the TFC and MBG, was seen as the TMBS is reduced in both groups (7.1 ± 0.49 vs. 7.1 ± 0.6, P-value = 0.04). The TTFC is instead higher in patients with MetS (83.9 ± 5.8 vs. 77.8 ± 6.7, P-value =0.024). Then we performed the same type of comparison between MetS and type 2 diabetic subgroup, in this comparison we observed how by analyzing the TFCs of the three coronary vessels, MetS patients have a slower coronary flow than patients with type 2 diabetes mellitus (TFC LAD 33.1 ± 5.6 vs. 30.6 ± 6.2, P = 0.04), (TFC RCA 27.2 ± 5.2 vs. 25 ± 5.3, P = 0.02), (TFC CX 27.9 ± 5.4 vs. 27.2 ± 5.6, P = 0.05). Comparing MBG of the three coronary vessels instead, the flow is lower in diabetic patients TTFC was higher in patients with metabolic syndrome (83.9 ± 5.8 vs. 82.7 ± 8.6, P-value = 0.02). While TMBS was lower in diabetic patients than in patients with metabolic syndrome (7.1 ± 0.49 vs. 6.7 ± 0.74, P-value = 0.01). Conclusions This study shows that patients with MetS had a major coronary microvascular dysfunction using TFC imaging technique, analysis compared to diabetics or hypertensive patients, these differences resulted to be statistically significant. A clinical evaluation of this parameters using TFC such in this study, might give further information about (CMD) in this patients in order to act to develop the best treatment to this patients and to improve their clinical condition.

Plasma Atherogenic Indexes Are Independent Predictors of Slow Coronary Flow

Background Although the pathophysiology of coronary slow flow (CSF) has not been fully elucidated, emerging data increasingly support potential role for subclinical diffuse atherosclerosis in the etiology of CSF. We aimed to investigate relationship between atherogenic indices and CSF. Methods 130 patients with CSF diagnosed according to Thrombolysis in Myocardial Infarction (TIMI)-frame count (TFC) method and 130 controls who had normal coronary flow (NCF) were included in this retrospective study. Atherogenic indices (atherogenic index of plasma [AIP], Castelli risk indices I and II [CRI-I and II]) were calculated using conventional lipid parameters Results The logistic regression analyses demonstrated that AIP (OR, 5.463; 95% confidence interval [CI], 1.357–21.991; p = 0.017) and CRI-II (OR, 1.624; 95% CI, 1.138–2.319; p = 0.008) were independent predictors of CSF. Receiver operating characteristic analysis showed that the optimal cutoff value to predict the occurrence of CSF was 0.66 for AIP (sensitivity, 59%; specificity, 73%; area under curve [AUC], 0.695; p < 0.001) and 3.27 for CRI-II (sensitivity, 60%; specificity, 79%; AUC, 0.726; p < 0.001). Conclusions AIP and CRI-II levels were independent predictors of CSF, suggesting that atherogenic dyslipidemia may contribute to the pathophysiology of CSF.

Angiographic profiles in patients of persistent non-valvular atrial fibrillation from a tertiary care center in north india

Funding Acknowledgements Type of funding sources: None. Background The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established. Atrial ischemia due to obstructive CAD has been identified as one of the key risk factors, leading to AF. However, sufficient evidence exists as to the presence of myocardial ischemia on stress imaging, even without the presence of obstructive CAD in AF patients. Slow flow and coronary tortuosity on angiogram can lead to downstream myocardial ischemia independent of CAD. Purpose We aimed to delineate the angiographic profiles in AF patients with attention to slow flow and tortuosity leading to ischemia in those without obstructive CAD. Methods The study was a nonrandomised, prospective, single-centre observational study of consecutive patients of persistent non valvular AF. Symptomatic patients despite optimal medical therapy (OMT) for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with known CAD or prior history of myocardial infarction were excluded. Further angiographic analysis was done in those without obstructive CAD to determine incidence of slow flow (&gt;27 corrected TIMI frame count) and tortuosity (presence of ≥3 fixed bends in an epicardial artery). Results A total of 70 patients were recruited and followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49). Hypertension (74%) was the commonest comorbidity followed by obesity (35%) and diabetes (30%). At CAG, 32/70 (45%) had obstructive CAD, 17/70 (24%) had non obstructive (&lt;50-70% stenosis) CAD and 21/70 (30%) had normal coronaries without atherosclerosis. Amongst patients without obstructive CAD (n = 38) slow flow was seen in 16/38 (42%) and coronary tortuosity in 11/38 (29%) patients. There ware no differences in terms of death, HF and FVR hospitalisations or stroke at follow up between the obstructive CAD vs no obstructive CAD. However in patients without obstructive CAD, hospitalisations for FVR was significantly increased in those having slow flow on CAG, 9/12 (75%) vs 7/26 (27%) in those without slow flow (p value = 0.005). The mean TIMI frame count was also significantly higher in those with FVR hospitalisations 35.3 ± 11 vs 25.8 ± 8.9 (p value = 0.005). TIMI frame count &gt;31 had a sensitivity of 83% and a specificity of 69% for predicting hospitalisations for FVR on ROC curve(AUC = 0.71). Conclusions CAD is closely related to AF and majority (70%) of our patients had evidence of atherosclerotic CAD on CAG in our study. A large proportion of patients with no evidence of obstructive CAD on CAG had slow flow or coronary tortuosity. Significantly increased hospitalisation for FVR seen in the slow flow group shows its significance and may lead to newer treatment modalities in future. Further larger studies looking at these aspects on CAG may give further insight as to the nature and prognosis of these entities.

Thrombus aspiration during primary percutaneous coronary intervention improved outcome in patients with STEMI and a large thrombus burden

Background The benefit of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) to patients with ST-segment elevation myocardial infarction (STEMI) remains controversial. This study aimed to assess TA's impact on the outcome and prognosis for patients with STEMI and a large thrombus burden during PPCI. Methods This retrospective study evaluated consecutive patients with STEMI and a large thrombus burden (thrombolysis in myocardial infraction [TIMI] thrombus grade ≥4) who underwent conventional PPCI (n = 126) or PPCI + TA (n = 208) between February 2017 and January 2019. The procedure outcome and clinical prognosis were compared. Results Postprocedural vessel diameter was larger, and corrected TIMI frame count (cTFC) was lower in the PPCI + TA compared with the PPCI group. The proportion of postprocedural TIMI 3 flow was 83.3% in the PPC group and 94.2% in the PPCI+TA group. During the 12-month follow-up, no significant differences existed in the incidence of cardiac death, reinfarction, stent thrombosis, target vessel revascularization, or stroke. Conclusion Application of TA in patients with STEMI and a large thrombus burden during PPCI may improve the procedural outcome, but it showed no benefit on the clinical prognosis in the 12-month follow-up. Longer follow-up studies are needed to confirm TA's clinical implications in patients with STEMI.