Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock...
Transcript of Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock...
![Page 1: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/1.jpg)
Φαινόμενο no reflow στην αγγειοπλαστική Αντιμετώπιση
ΘΩΜΑΣ ΠΑΠΑΔΟΠΟΥΛΟΣ, MD, PHD
ΕΠΕΜΒΑΤΙΚΟΣ ΚΑΡΔΙΟΛΟΓΟΣ
ΙΑΤΡΙΚΟ ΔΙΑΒΑΛΚΑΝΙΚΟ ΚΕΝΤΡΟ
![Page 2: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/2.jpg)
Δεν έχω να δηλώσω κάποια αντίθεση συμφερόντων σχετικά με την παρούσα ομιλία
![Page 3: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/3.jpg)
Ασθενής 82 ετών, με κατώτερο έμφραγμα, με καθυστερημένη προσέλευση, μη θρομβολυθέν
![Page 4: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/4.jpg)
Μετά την τοποθέτηση του stent, διάνοιξη του αγγείου,ΤΙΜΙ 2, χωρίς μυοκαρδιακό blushing
![Page 5: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/5.jpg)
Φαινόμενο μη επαναροής(No Reflow phenomenon)
Μια δραματική εξέλιξη της επαναγγείωσης ενός στεφανιαίου αγγείου
![Page 6: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/6.jpg)
Ορισμός
Αποτελεί το φαινόμενο κατά το οποίο υπάρχει υποαιμάτωση τμήματος του μυοκαρδίου, παρόλη την παρουσία βατών επικαρδιακών αρτηριών
![Page 7: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/7.jpg)
No-reflow phenomenon
Επικαρδιακή επαναγγείωση= μυοκαρδιακή επαναιμάτωση;
The No-reflow is a dissociation between epicardialartery patency and myocardial perfusion
![Page 8: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/8.jpg)
Αγγειογραφικός ορισμός του φαινομένου
Αποτελεί την παρουσία ενδοστεφανιαίας ροής TIMI ≤2 σεαπουσία στένωσης, θρόμβωσης, διαχωρισμού ήαγγειόσπασμου του επικαρδιακού αγγείου.
![Page 9: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/9.jpg)
MYOCARDIAL BLUSH GRADES DEFINED
Myocardial Blush Grades
Grade 0(MBG-0
Failure of dye to enter the microvasculature. Either minimal or no ground glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit artery indicating lack of tissue-level perfusion.
Grade 1(MBG-1)
Dye slowly enters but fails to exit the microvasculature. There is the ground glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit lesion that fails to clear from the microvasculature, and dye staining is present on the next injection (approximately 30 seconds between injections).
Grade 2(MBG-2)
Delayed entry and exit of dye from the microvasculature. There is the ground glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit lesion that is strongly persistent at the end of the washout phase (i.e., dye is strongly persistent after three cardiac cycles of the washout phase and either does not or only minimally diminishes in intensity during washout).
Grade 3(MBG-3)
Normal entry and exit of dye from the microvasculature. There is the ground glass appearance (“blush”) or opacification of the myocardium in the distribution of the culprit lesion that clears normally and is either gone or only mildly/moderately persistent at the end of the washout phase (i.e., dye is gone or is mildly/moderately persistent after three cardiac cycles of the washout phase and noticeably diminishes in intensity during the washout phase), similar to that in an uninvolved artery. Blush that is of only mild intensity throughout the washout phase but fades minimally is also classified as grade 3.
van 't Hof AW, Liem A, Suryapranata H, et al. Circulation 1998;97:2302-6. PMID: 9639373.
![Page 10: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/10.jpg)
Επίπτωση
INCIDENCE OF ANGIOGRAPHIC NO-REFLOW IN VARIOUS PCI SETTINGS
All PCI 0.6%–2%
Primary PCI 8.8%–11.5%
SVG PCI 8%–40%
Rotational atherectomy Upto 16%
Jaffe et al. MVO and Mechanisms. Circualtion 2008.Jaffe et al. Prevention and treatment of no reflow. JACC 2010.
![Page 11: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/11.jpg)
Επίπτωση στο STEMI
▪ Ποικίλει μεταξύ 5-50% των περιπτώσεων PPCI, ανάλογα με τη μέθοδο εκτίμησης
![Page 12: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/12.jpg)
Επιπτώσεις ενδοστεφανιαίου Θρόμβου και φαινομένου μη επαναρροής (no reflow)
Η παρουσία θρόμβου και/η no reflow κατά τη διάρκεια της Αγγειοπλαστικής, συνοδεύεται από δυσμενή αποτελέσματα που περιλαμβάνουν:
• Ελάττωση του ποσοστού επιτυχούς αποτελέσματος
• Αυξημένα ποσοστά οξείας απόφραξης του αγγείου
• Δυσμενή κοιλιακή αναδιαμόρφωση
• Μείζονες επιπλοκές [death-MI-emergent CABG]
![Page 13: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/13.jpg)
Επιπτώσεις μειωμένης ροής κατά TIMI
Κλινικές μελέτες έδειξαν ότι ροή TIMI ≤2 συνοδεύεται απόχειρότερη πρόγνωση, όταν τη συγκρίνουμε με ροή TIMI 3στο πέρας της αγγειοπλαστικής.
Μάλιστα ροή η TIMI 2 δεν είναι ευνοϊκότερη από την ροήTIMI 1 ή 0 σχετικά με το αποτέλεσμα
![Page 14: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/14.jpg)
Πιθανότητα επιβίωσης με no reflow
![Page 15: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/15.jpg)
Eπιβίωση με no reflow
![Page 16: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/16.jpg)
![Page 17: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/17.jpg)
Τύποι φαινομένου μη επαναρροής
ΜΟΝΙΜΟ
• Result of anatomical irreversiblechanges of coronary microcirculation
• Undergo unfavorable LV remodeling
ΠΑΡΟΔΙΚΟ
• Result of functional & thus reversiblechanges of microcirculation
• Maintain their left ventricle volumesunchanged over time
![Page 18: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/18.jpg)
Τύποι φαινομένου μη επαναρροής
MYOCARDIAL INFARCTION REPERFUSION NO-REFOW
Definition no-reflow in the setting of pharmacological and/or mechanical revascularization for acute myocardial infarction
INTERVENTIONAL NO REFLOW
Definition no-reflow during percutaneous coronary interventions especially rotational atherectomy, vein graft interventions
![Page 19: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/19.jpg)
Κλινική εικόνα
➢Θωρακικό άλγος
➢ΗΚΓικές αλλοιώσεις
➢Δυσλειτουργία αριστερής κοιλίας
➢Αιμοδυναμική επιβάρυνση
➢Αρρυθμίες
➢Ασυμπτωματική;
![Page 20: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/20.jpg)
Διάγνωση της μη επαναρροής
Niccoli, EHJ, 2010
![Page 21: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/21.jpg)
Παθοφυσιολογία
In humans, no-reflow is caused bythe variable combination of 4pathogenetic components:
1. Distal Atherothrombotic Embolization
2. Ischemic Injury
3. Reperfusion Injury
4. Susceptibility Of CoronaryMicrocirculation To Injury
Distal embolization
Ischemic injury
Individual susceptibility
Reperfusioninjury
J Am Coll Cardiol. 2009;54(4):281-292.
![Page 22: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/22.jpg)
Where is the problem???
• TIMI 3 FLOW ≠ Myocardial perfusion
• 16% of TIMI 3 flow post pPCI have no-reflow as shown by cardiac MRI (infarct extension) *Ito et al. Circulation 2007.
• NO REFLOW = MICROVASCULAR OBSTRUCTION (MVO)
• Microvasculature <200µm
![Page 23: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/23.jpg)
Μαζική διήθηση της στεφανιαίας μικροκυκλοφορίας, από λευκοκύτταρα και αιμοπετάλια, κατά την επαναιμάτωση
![Page 24: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/24.jpg)
Παθοφυσιολογία και προγνωστικοί παράγοντες του
φαινομένου μη επαναρροής
• Thrombus burdenDistal
embolization
Ischemia• Ischemia duration
• Ischemia extent
• Neutrophil count
• ET-1 levels
• TXA2 levels
• Mean platelet volume or reactivity
Reperfusion
• Diabetes
• Acute hyperglycemia
• Hypercholesterolemia
• Lack of pre-conditioning
Individual susceptibility
![Page 25: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/25.jpg)
Initial low density lipoprotein serum level as a
predictor of no-reflow after primary percutaneous
coronary intervention
Abdallah Almaghraby, Yehia Saleh, Basma Hammad, Mahmoud Abdelnaby, Haitham Badran
Atherosclerosis
Volume 263, Pages e163-e164 (August 2017) DOI: 10.1016/j.atherosclerosis.2017.06.520
Copyright © 2017 Terms and Conditions
![Page 26: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/26.jpg)
Θεραπεία φαινομένου επαναρροής
▪ Δεν υπάρχουν μεγάλες τυχαιοποιημένες μελέτες
▪ Από τις υπάρχοντες μελέτες δεν προέκυψαν ασφαλή συμπεράσματα
▪ Επομένως, η θεραπεία δεν υπόκεινται σε σαφείς κατευθυντήριες οδηγίες
![Page 27: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/27.jpg)
Θεραπεία ή Πρόληψη;
![Page 28: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/28.jpg)
Πρόληψη του φαινομένου μη επαναρροής
•Πριν την έναρξη του ισχαιμικού πόνου
•Πριν την επαναιμάτωση
•Εντός του αιμοδυναμικού εργαστηρίου
![Page 29: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/29.jpg)
Διαχείριση της ιδιαιτερότητας του ασθενούς για μικροκυκλοφοριακή βλάβη
• The DIGAMI (Diabetes Mellitus Insulin-Glucose Infusion in AcuteMyocardial Infarction) study demonstrated that periprocedural reduction ofblood glucose was associated with a reduction of infarct size
• Iwakura et al. have demonstrated that chronic statin therapy in patientswith or without hypercholesterolemia is associated with lower prevalence ofno-reflow and better functional recovery.
• Induction of ischemic pre-conditioning by drugs or nonpharmacologic stimulisuch as remote ischemia of the arms
• Avoidance of substances potentially blocking pre-conditioning likesulfonylureas and high doses of alcohol
![Page 30: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/30.jpg)
Διαχείριση της ισχαιμικής βλάβης
➢Μειώνοντας το χρόνο από την έναρξη του συμπτώματος έως τηδιάνοιξη του αγγείου.
(↓ συνολικού ισχαιμικού χρόνου)
➢Μειώνοντας την έκταση της ισχαιμίας, με φάρμακα που βελτιώνουντην μυοκαρδιακή αιμάτωση και περιορίζοντας την ανάγκη τουμυοκαρδίου για οξυγόνο.
![Page 31: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/31.jpg)
![Page 32: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/32.jpg)
Θρομβοαναρρόφηση
• Αντικρουόμενα συμπεράσματα από τις μελέτες
DEAR MI, REMEDIA, TAPAS vs TASTE, TOTAL
• Σύσταση για αναρρόφηση θρόμβου, σε επίπεδο PPCI, σε επιλεγμένους ασθενείς, με μεγάλο φορτίο θρόμβου, (Class iib, level of evidence A)
( 2014 ESC/EACTS guidelines on myocardial revascularization)
![Page 33: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/33.jpg)
Burzotta, ESC 2009; Eur Heart J 2009 30(18):2193-2203
X-AMINE STX-SIZER
AntoniucciANGIOJET
NO
N-M
AN
UA
L TH
RO
MB
ECTO
MY
TVAC VAMPIRE
RESCUE Kaltoft
MA
NU
AL
ASP
IRAT
ION
REMEDIADIVER CE PIHRATEDe Luca
PRONTO DEAR-MI
EXPORT TAPASEXPORT EXPIRA
2,686 Patients
Median Follow-Up: 365 Days (significantly extended compared to published FU
of included trials: 135 days)
ATTEMPT: 11 Included Trials
![Page 34: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/34.jpg)
Burzotta, ESC 2009; Eur Heart J 2009 30(18):2193-2203
MANUAL ASPIRATION TRIALSNON-MANUAL THROMBECTOMY TRIALS
Estimated NNT: 34
300 600 900 1200
80%
85%
90%
95%
100%
300 600 900 1200
80%
85%
90%
95%
100%
p = 0.482
p = 0.011
Time to Death (days) Time to Death (days)
Standard PCI
ThrombectomyStandard PCI
Thrombectomy
Cumulative Survival Cumulative Survival
ATTEMPT: Impact of Type of Thrombectomy Device on Mortality
![Page 35: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/35.jpg)
Randomized trial of manual aspiration Thrombectomy + PCI vs. PCI Alone in
STEMI (TOTAL)
SS JOLLY, JA CAIRNS, S YUSUF, B MEEKS, J POGUE, MJ ROKOSS, S KEDEV, L THABANE, G STANKOVIC, R MORENO, A GERSHLICK, S CHOWDHARY, S LAVI, K NIEMELÄ, PG STEG,
I BERNAT, Y XU, WJ CANTOR, C OVERGAARD, C NABER, AN CHEEMA, RC WELSH, OF BERTRAND, A AVEZUM, R BHINDI, S PANCHOLY, SV RAO, MK NATARAJAN,
JM TEN BERG, O SHESTAKOVSKA, P GAO, P WIDIMSKY, V DŽAVÍK
ON BEHALF OF THE TOTAL INVESTIGATORS
![Page 36: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/36.jpg)
Conclusions
• Routine thrombectomy compared to PCI alone with only bailout thrombectomy did not reduce CV death, MI, shock or heart failure within 180 days
• Routine thrombectomy was associated with increased risk of stroke within 30 days
• TOTAL and TASTE emphasize the need to conduct large randomized trials of common interventions even when small trials appear positive
![Page 37: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/37.jpg)
Φαρμακευτική αντιμετώπιση (1)
![Page 38: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/38.jpg)
Φαρμακευτική αντιμετώπιση (2)
![Page 39: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/39.jpg)
ABCIXIMAB
• RELAX-AMI study 2007 Upstream beneficial in reducing infarct size, no reflow incidence
• Thiele et al (CIRCULATION 2008)Intracoronary administration prior to PTCA beneficial
• CADILLAC 2002 No superior benefit to placebo in absence of thienopyridineloading
![Page 40: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/40.jpg)
Tirofiban
• ONTIME 2 STUDY 2008 Infusion of tirofiban upstream beneficial
• Reduces no reflow incidence, infarct size on follow up
![Page 41: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/41.jpg)
IC infusion of Gp IIb-IIIa via dedicated perfusion catheter?
• May reduce thrombus burden at site of lesion in a most efficient manner
• May reduce no reflow phenomenon
• May address residual thrombus to prevent SAT
• May reduce cost with only bolus strategy
![Page 42: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/42.jpg)
INFUSE-AMI Conclusions
In patients presenting early within the course of
large anterior STEMI undergoing primary PCI with
bivalirudin:
1. Bolus IC abciximab delivered via ClearWay Rx
catheter resulted in significant but modest reduction
in infarct size at 30 days
2. Manual aspiracion with 6F Export catheter did not
reduce MI size
3. The utility of combined aspiration + local delivery of
IC abciximab deserves further studies
![Page 43: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/43.jpg)
ΑδενοσίνηAMISTAD II Infarct Size
57% reduction in median infarct size with 70 μg/kg/min x 3hrs, relative to placebo
p=0.122
26%
23%
11%
10%
20%
30%
40%
Placebo 50 μg 70 μg
Median LV Infarct Size (%)
p=0.028
0%
![Page 44: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/44.jpg)
Adenosine as an Adjunct to Reperfusion in the Treatment of Acute Myocardial Infarction post hoc study (n=2118)
(AMISTAD-2 et al. EHJ 2006)
![Page 45: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/45.jpg)
Αδενοσίνη & Νιτροπρωσικό νάτριο
• REFLO-STEMI study, comparing the benefits in terms of MVO and infarct size of intracoronary adenosine, sodium nitroprusside and standard therapy; primary endpoint of the trial is CMRI measured infarct size at 48 and 72 h after pPCI
![Page 46: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/46.jpg)
Conclusions:
High-dose intracoronary adenosine and SNP during PPCI did not reduce infarct size or MVO measured by CMR imaging. Furthermore, adenosine may adversely affect mid-term clinical outcome and should not be used during PPCI to prevent reperfusion injury
![Page 47: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/47.jpg)
BMC Cardiovasc Disord. 2018; 18: 3.Published online 2018 Jan 10. doi: 10.1186/s12872-017-0722-zPMCID: PMC5763527
Effect of intracoronary agents on the no-reflow phenomenon during primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction: a network meta-analysisXiaowei Niu,1 Jingjing Zhang,2 Ming Bai,3 Yu Peng,3 Shaobo Sun,4 and Zheng Zhangcorresponding author3
![Page 48: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/48.jpg)
![Page 49: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/49.jpg)
The very early benefit of ticagrelor in STEMI is co-mediated by adenosine cardioprotectionmaintaining/ improving myocardial microcirculatory function, as well as via platelet inhibition or possibly other pleiotropic effects.
Ticagrelor vs. Placebo/ Clopidogrel With Aspirin in Anterior STEMI Patients Treated With Primary PCI
![Page 50: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/50.jpg)
SUGGESTED INTRACORONARY DRUG ADMINISTRATION REGIMENS FOR PREVENTION/TREATMENT OF NO-REFLOW
Verapamil Boluses of 100–200 µg up to four doses upto 1000µg
Nicardipine 200µg bolus intracoronary
Adenosine Boluses of 24 µg up to four doses or 70µg/kg/mt infusion for 3 hours
Sodium nitroprusside
Boluses of 100 µg up to total of 1,000 µg
Nitroglycerin Boluses of 100–200 µg up to four doses
Nicorandil Bolus of 2 mg intracoronary
![Page 51: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/51.jpg)
Current guidelines suggested approach for no-reflow prevention
ESC guidelines, EHJ, 2014
![Page 52: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/52.jpg)
Σας ευχαριστώ πολύ για την προσοχή σας
![Page 53: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/53.jpg)
![Page 54: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/54.jpg)
![Page 55: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/55.jpg)
Διάταξη τίτλου και περιεχομένου με λίστα
• Προσθέστε την πρώτη κουκκίδα εδώ
• Προσθέστε τη δεύτερη κουκκίδα εδώ
• Προσθέστε την τρίτη κουκκίδα εδώ
![Page 56: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/56.jpg)
Διάταξη τίτλου και περιεχομένου με γράφημα
0
1
2
3
4
5
6
Κατηγορία 1 Κατηγορία 2 Κατηγορία 3 Κατηγορία 4
Σειρά 1 Σειρά 2 Σειρά 3
![Page 57: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/57.jpg)
Διάταξη δύο περιεχομένων με πίνακα
• Πρώτη κουκκίδα εδώ
• Δεύτερη κουκκίδα εδώ
• Τρίτη κουκκίδα εδώ
Ομάδα 1 Ομάδα 2
Κλάση 1 82 95
Κλάση 2 76 88
Κλάση 3 84 90
![Page 58: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/58.jpg)
Διάταξη τίτλου και περιεχομένου με SmartArt
Τίτλος βήματος 1
Τίτλος βήματος 2
Τίτλος βήματος 3
Τίτλος βήματος 4
![Page 59: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/59.jpg)
Κάντε κλικ για τίτλοΠΡΟΣΘΕΣΤΕ ΚΕΙΜΕΝΟ
![Page 60: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/60.jpg)
Κάντε κλικ για τίτλο
ΠΡΟΣΘΕΣΤΕ ΚΕΙΜΕΝΟ
• Προσθέστε κείμενο
ΠΡΟΣΘΕΣΤΕ ΚΕΙΜΕΝΟ
• Προσθέστε κείμενο
![Page 61: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/61.jpg)
Κάντε κλικ για τίτλο
![Page 62: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/62.jpg)
![Page 63: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/63.jpg)
Κάντε κλικ για τίτλο
• Προσθέστε κείμενο
Προσθέστε κείμενο
![Page 64: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/64.jpg)
Κάντε κλικ για τίτλοΠροσθέστε κείμενο
![Page 65: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/65.jpg)
Περιφερικός Θρομβοεμβολισμός (1)• Distal embolization Emboli of different sizes
can originate from epicardial coronarythrombus and fissured atheroscleroticplaques, in particular during PPCI.
• Experimental observations have shown, thatmyocardial blood flow decreases irreversibly,when microspheres obstruct more than 50 %of coronary capillaries.
![Page 66: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/66.jpg)
Περιφερικός Θρομβοεμβολισμός (2)• Also occurs during elective PCI,
especially in Vein Grafts Angioplasties.
• Strict correlation between microemboliand Troponin I elevation.
• Contributes in Inflammatory Reaction andContractile Dysfunction.
• Induces Vasoconstriction, as confirmedby high serotonin levels.
![Page 67: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/67.jpg)
Ισχαιμική Βλάβη
• No-Reflow area gets swollen. Certain morphological changes are seen that results to no reflow phenomenon
• The capillary endothelium damaged
• Areas of regional swelling with intraluminal protrusions, thatin some plug the capillary lumen.
• Cellular edema compressing the capillaries
• Cell contracture in the ischemic zone also may contribute tothe microvascular compression.
![Page 68: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/68.jpg)
Βλάβη Επαναιμάτωσης
Massive infiltration of coronary microcirculation by neutrophils and platelets at the time of reperfusion
Release of oxygen free radicals, proteolytic enzymes and pro-inflammatory mediators
Subsequent adhesion at the endothelial surface and migration in the surrounding tissue
Tissue and endothelial damage
Sustained vasoconstriction of coronary microcirculation. Neutrophilsalso form aggregates with platelets, that plug capillaries thus
mechanically blocking flow
Finally vasoconstrictors released by damaged endothelial cells, neutrophils and platelets
![Page 69: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/69.jpg)
%age of optimal reperfusion, CADILLAC TRIAL
100 patients with STEMI treated by PPCI
93 patients with TIMI 3
49 patients with TIMI 3and MBG 2 or 3
35 patients with TIMI 3and MBG 2 or 3 and
STR>70 %
1 pt with TIMI 0-16 pts with TIMI 2
44 pts with MBG 0/1
14 pts with STR < 70%
Evaluation of post procedural
TIMI flow
Evaluation of post procedural
MBG
Evaluation of post procedural STR>
70%
![Page 70: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/70.jpg)
Reffelmannand Kloner. Heart 2002;87:162-168
![Page 71: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/71.jpg)
From: No-reflow: again prevention is better than treatmentEur Heart J. 2010;31(20):2449-2455. doi:10.1093/eurheartj/ehq299
Eur Heart J | Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions
please email: [email protected]
![Page 72: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/72.jpg)
![Page 73: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/73.jpg)
Reperfusion therapy—What’s with the
obstructed, leaky and broken capillaries?
D. Neil Granger, Peter R. Kvietys
Pathophysiology
Volume 24, Issue 4, Pages 213-228 (December 2017)
DOI: 10.1016/j.pathophys.2017.09.003
Copyright © 2017 Elsevier B.V. Terms and Conditions
![Page 74: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/74.jpg)
THROMBOLYSIS IN MYOCARDIAL INFARCTION FLOW GRADING SYSTEM DEFINED
Thrombolysis in Myocardial Infarction Flow Grading System
Grade 0
Complete occlusion of the infarct-related artery
Grade 1
Some penetration of contrast material beyond the point of obstruction but without perfusion of the distal coronary bed
Grade 2
Perfusion of the entire infarct vessel into the distal bed but with delayed flow when compared with a normal artery
Grade 3
Full perfusion of the infarct vessel with normal flow
Chesebro JH, Knatterud G, Roberts R, et al. Circulation 1987;76:142-54. PMID: 3109764.
![Page 75: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/75.jpg)
![Page 76: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/76.jpg)
Inci
de
nce
(%)
In-Hospital Clinical Outcomes
Adjusted Odds Ratio for Mortality= 2.21, 95% CI 1.97-2.47, p<0.001
P<0.0001 for each outcome
![Page 77: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/77.jpg)
Fig. 2
Pathophysiology 2017 24, 213-228DOI: (10.1016/j.pathophys.2017.09.003)
Copyright © 2017 Elsevier B.V. Terms and Conditions
![Page 78: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/78.jpg)
Effects of Duration of Preceeding Ischemia on No Reflow
>20% Primary PCI
<2% Elective PCI
![Page 79: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/79.jpg)
ΙΣΤΟΡΙΚΗ ΑΝΑΔΡΟΜΗ
The first clinical observation of coronary no-reflow was reported by Schofer etal.in 1985.
In 1989, Wilson et al. observed persistent angina with ST elevation in associationwith a slow angiographic antegrade flow despite a widely patent angioplasty site infive patients immediately after PTCA of a thrombus containing lesion.
In 1991,Pomerantz et al. reported five more cases of no- reflow successfullytreated by intracoronary verapamil.
The first clinical case of no-reflow during PTCA for acute myocardial infarction wasreported by Feld et al. in 1992.
![Page 80: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/80.jpg)
Παθοφυσιολογία no Reflow
▪ No reflow results from obstruction of the myocardial
microcirculation, defined as vessels 200 μm in diameter.
▪ Preexisting microvascular dysfunction may exacerbate
the degree of microvascular obstruction that develops
after both elective and infarct-related PCI.
![Page 81: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/81.jpg)
TIMI GRADING FOR THROMBUS
JACC vol.50,2007
![Page 82: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/82.jpg)
Forrest plot of weighted mean difference of the long‐term left ventricular ejection fraction in
deferred‐ vs immediate‐stenting groups.
Jianzhong Qiao et al. J Am Heart Assoc 2017;6:e004838
© 2017 Jianzhong Qiao et al.
![Page 83: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/83.jpg)
Individual susceptibility to No-reflow Ατομική Ευαισθησία στη μη επαναρροή
Timmer et al, AJC, 2005 Iwakura et al, JACC, 2003
Diabetes and acute hyper-glycaemia
![Page 84: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/84.jpg)
Golino et al, Circulation, 1987 Iwakura et al, EHJ, 2006
Individual susceptibility to No-reflow
Ατομική Ευαισθησία στη μη επαναρροή
Hypercholesterolemia
![Page 85: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/85.jpg)
Atherosclerosis 2017 263, e163-e164DOI: (10.1016/j.atherosclerosis.2017.06.520)
Copyright © 2017 Terms and Conditions
![Page 86: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/86.jpg)
Individual susceptibility to No-reflow Ατομική Ευαισθησία στη μη επαναρροήPrior drug therapy
Niccoli et al, AJC, 2010
![Page 87: Φαινόμενο no reflow στην αγγειοπλαστική ......reduce CV death, MI, shock or heart failure within 180 days • Routine thrombectomy was associated with increased](https://reader034.fdocuments.in/reader034/viewer/2022042305/5ed155f3efd7b2537304c982/html5/thumbnails/87.jpg)
Karila-Cohen et al, EHJ, 1999
Individual susceptibility to No-reflow
Ατομική Ευαισθησία στη μη επαναρροή
Pre-infarction angina