An Overview on Management of No-Reflow

Abstract

Primary percutaneous angioplasty (pPCI), represents the reperfusion strategy of choice for patients with STEMI according to current international guidelines of the European Society of Cardiology. Coronary no-reflow is characterized by angiographic evidence of slow or no anterograde epicardial flow, resulting in inadequate myocardial perfusion in the absence of evidence of mechanical vessel obstruction. No reflow (NR) is related to a functional and structural alteration of the coronary microcirculation. Although NR has been a known phenomenon for many years, the efficacy of therapies in animal models has only partially translated to humans with benefits on surrogate endpoints but no impact on endpoints such as cardiovascular mortality. To date, the main treatment of NR is based on the use of intracoronary drugs that can result in vasodilation in the coronary arteries. Several studies have shown possible efficacy for vasodilator drugs, such as adenosine, calcium channel blockers, and sodium nitroprusside, used singularly or in combination, and antiplatelet drugs such as glycoprotein IIB/IIIA inhibitors. Alongside these, nonpharmacologic treatment strategies such as coronary post-conditioning, remote ischemic conditioning, or tools to reduce the embolization of thrombotic material and increase coronary flow have also been investigated in several trials, but there is still no therapy, single or in combination, aimed at reducing ischemia/reperfusion injury that is clearly associated with improved clinical outcomes.