Prevention and Treatment of Microvascular Obstruction-Related Myocardial Injury and Coronary No-Reflow Following Percutaneous Coronary Intervention: A Systematic Approach
TLDR
A systematic approach to prevention and treatment of MVO in different clinical settings is advocated, requiring a better understanding of intracellular cardioprotective pathways such as the blockade of the mitochondrial permeability transition pore.Abstract:
Microvascular obstruction (MVO) commonly occurs following percutaneous coronary interventions (PCI), may lead to myocardial injury, and is an independent predictor of adverse outcome. Severe MVO may manifest angiographically as reduced flow in the patent upstream epicardial arteries, a situation that is termed “no-reflow.” Microvascular obstruction can be broadly categorized according to the duration of myocardial ischemia preceding PCI. In “interventional MVO” (e.g., elective PCI), obstruction typically involves myocardium that was not exposed to acute ischemia before PCI. Conversely “reperfusion MVO” (e.g., primary PCI for acute myocardial infarction) occurs within a myocardial territory that was ischemic before the coronary intervention. Interventional and reperfusion MVO have distinct pathophysiological mechanisms and may require individualized therapeutic approaches. Interventional MVO is triggered predominantly by downstream embolization of atherosclerotic material from the epicardial vessel wall into the distal microvasculature. Reperfusion MVO results from both distal embolization and ischemia-reperfusion injury within the subtended ischemic tissue. Management of MVO and no-reflow may be targeted at different levels: the epicardial artery, microvasculature, and tissue. The aim of the present report is to advocate a systematic approach to prevention and treatment of MVO in different clinical settings. Randomized clinical trials have studied strategies for prevention of MVO and no-reflow; however, the efficacy of measures for reversing MVO once no-reflow has been demonstrated angiographically is unclear. New approaches for prevention and treatment of MVO will require a better understanding of intracellular cardioprotective pathways such as the blockade of the mitochondrial permeability transition pore.read more
Citations
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Paul A.J. Krijnen,Paul A.J. Krijnen,Nynke E. Hahn,Nynke E. Hahn,Ivana Kholová,Umit Baylan,Umit Baylan,Jessica A. Sipkens,Jessica A. Sipkens,Floris P. J. van Alphen,Alexander B.A. Vonk,Alexander B.A. Vonk,S. Simsek,Christof Meischl,Christof Meischl,Casper G. Schalkwijk,Jaap D. van Buul,Victor W. M. van Hinsbergh,Victor W. M. van Hinsbergh,Hans W.M. Niessen,Hans W.M. Niessen +20 more
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The no-reflow phenomenon: State of the art
TL;DR: The pathophysiological mechanisms of NR are described and the tools available for diagnosing it are described, which may provide relevant therapeutic targets for reducing NR and improving the prognosis for patients.
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No-Reflow Phenomenon Maintaining Vascular Integrity
TL;DR: Clinical evidence is now clinical evidence that no-reflow is a strong predictor of long-term mortality that is independent of and beyond that provided by infarct size.
References
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Journal ArticleDOI
Myocardial Reperfusion Injury
TL;DR: This review focuses on the mechanisms of the injury, on attempts to protect the heart against it, and on promising new approaches to cardioprotection during percutaneous coronary intervention.
Journal ArticleDOI
ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention-summary article : A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention)
Sidney C. Smith,Ted Feldman,John W. Hirshfeld,Alice K. Jacobs,Morton J. Kern,Spencer B. King,Douglass A. Morrison,William W. O'Neill,Hartzell V. Schaff,Patrick L. Whitlow,David O. Williams,Elliott M. Antman,Cynthia D. Adams,Jeffrey L. Anderson,David P. Faxon,Valentin Fuster,Jonathan L. Halperin,Loren F. Hiratzka,Sharon A. Hunt,Rick A. Nishimura,Joseph P. Ornato,Richard L. Page,Barbara Riegel +22 more
TL;DR: The American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) 2005 Guideline Update for Percutaneous Coronary Intervention (PCI) contains changes in the recommendations, along with supporting text.
Journal ArticleDOI
2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Frederick G. Kushner,Mary M. Hand,Sidney C. Smith,Spencer B. King,Jeffrey L. Anderson,Elliott M. Antman,Steven R. Bailey,Eric R. Bates,James C. Blankenship,Donald E. Casey,Lee A. Green,Judith S. Hochman,Alice K. Jacobs,Harlan M. Krumholz,Douglass A. Morrison,Joseph P. Ornato,David L. Pearle,Eric D. Peterson,Michael A. Sloan,Patrick L. Whitlow,David O. Williams +20 more
TL;DR: A primary challenge in the development of clinical practice guidelines is keeping pace with the stream of new data on which recommendations are based as discussed by the authors, and the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) is to respond promptly to new evidence.
Journal ArticleDOI
2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)†
Frederick G. Kushner,Mary M. Hand,Sidney C. Smith,Spencer B. King,Jeffrey L. Anderson,Elliott M. Antman,Steven R. Bailey,Eric R. Bates,James C. Blankenship,Donald E. Casey,Lee A. Green,Judith S. Hochman,Alice K. Jacobs,Harlan M. Krumholz,Douglass A. Morrison,Joseph P. Ornato,David L. Pearle,Eric D. Peterson,Michael A. Sloan,Patrick L. Whitlow,David O. Williams +20 more
TL;DR: A primary challenge in the development of clinical practice guidelines is keeping pace with the stream of new data on which recommendations are based as discussed by the authors, and the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) is to respond promptly to new evidence.
Journal ArticleDOI
2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update).
Frederick G. Kushner,Mary M. Hand,Sidney C. Smith,Spencer B. King,Jeffrey L. Anderson,Elliott M. Antman,Steven R. Bailey,Eric R. Bates,James C. Blankenship,Donald E. Casey,Lee A. Green,Judith S. Hochman,Alice K. Jacobs,Harlan M. Krumholz,Douglass A. Morrison,Joseph P. Ornato,David L. Pearle,Eric D. Peterson,Michael A. Sloan,Patrick L. Whitlow,David O. Williams +20 more
TL;DR: A primary challenge in the development of clinical practice guidelines is keeping pace with the stream of new data on which recommendations are based as mentioned in this paper, and the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) is to respond promptly to new evidence.