ARYA Atherosclerosis Journal

Does Adjunctive Prophylactic Intracoronary Infusion of Low Dose Alteplase Prevent No-Reflow Phenomenon During Primary Percutaneous Coronary Intervention?

Document Type : Original Article

Authors

Mohammad Hashemi 1
Jalal Ostovan 2
Masoumeh Sadeghi 3
Ehsan Shirvani 4
Ali Safaei 5
Shahin Sanaei 6

1 Department of Cardiology, Chamran Cardiovascular and Medical Research Hospital, Isfahan University of Medical Sciences, Isfahan, Iran

2 Department of Cardiology,School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

3 Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

4 Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

5 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

6 Department of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

https://doi.org/10.48305/arya.2023.41614.2890
Abstract
INTRODUCTION: Primary percutaneous coronary intervention (PPCI) is the gold standard approach to restore blood flow in ST-segment elevation myocardial infarction (STEMI); however, the no-reflow phenomenon as a potential complication of PPCI can worsen the outcomes. It has been hypothesized that adjunctive prophylactic intracoronary infusion of low-dose fibrinolytic might improve the PPCI outcomes; however, this theory is a matter of debate. The current study aims to investigate the value of adjunctive prophylactic intracoronary low-dose alteplase to prevent the no-reflow phenomenon in patients with STEMI.
METHOD: This case-control study was conducted on 80 STEMI patients who underwent PPCI. The patients were assigned into the case group who were intervened by 10 mg adjunctive intracoronary alteplase immediately at the end of the balloon angioplasty (n=40) and controls (n=40) who underwent conventional PPCI only. The angioplasty-associated outcomes including final TIMI score, need for no-reflow treatment, ST-segment resolution, post-PPCI complications, and death were compared between the groups.
RESULTS: Alteplase use was accompanied by significantly improved final TIMI flow scores (P-value<0.001) and fewer requirements for no-reflow treatments (P-value<0.001); however, it did not improve the ST-segment resolution (P-value=0.491). The mortality rate and post-angioplasty complications did not differ between the groups (P-value>0.05).
CONCLUSION: Based on the findings of this study, adjunctive infusion of low-dose intracoronary alteplase during PPCI could not efficiently prevent the no-reflow phenomenon. Although the final TIMI flow and need for post-stenting no-reflow treatment improved, ST-segment resolution did not occur dramatically. Given that, this approach requires further investigations and should be considered cautiously.
 

Keywords

ST-elevation myocardial infarction
Tissue activator plasminogen
Alteplase
No-reflow phenomenon
Case-control studies
1. Sadeghi M, Heshmat-Ghahdarijani K, Talaei M, Safaei A, Sarrafzadegan N, ‎Roohafza H. The predictive value of atherogenic index of plasma in the ‎prediction of cardiovascular events; a fifteen-year cohort study. Adv Med Sci 2021; 66(2): 418-23.https://doi.org/10.1016/j.advms.2021.09.003
2. Kermani-Alghoraishi M, Heshmat-Ghahdarijani K, Sanei H, Sadeghi M, Asadi A, Safaei A. Does allopurinol improve inflammatory biomarkers and post-revascularization coronary blood flow in Non-STEMI patients?. Eur J Prev Cardiol 2022; 29(Supplement_1): zwac056.5. https://doi.org/10.1093/eurjpc/zwac056.055
3. Saddique MA, Jamshaid MM, Abbas S, Jabeen K. The outcome of Intracoronary Tirofiban administration at Primary Percutaneous Coronary Intervention in St-Elevation Myocardial Infarction Patients. Pak J Cardiovasc Interv 2022; 2(1): 20-7. https://doi.org/10.58889/PJCVI.2.20.27
4. Iqbal MU, Iqbal M, Ali A, Riaz S, Imtiaz U, Ahmad K. The Outcome of Intracoronary Tirofiban Administation at Primary Percutenous Coronary Intervention in ST-Elevation Myocardial Infarction Patients. Pak J Med Health Sci 2022; 16(11): 670-.https://doi.org/10.53350/pjmhs20221611670
5. Huang D, Qian J, Liu Z, Xu Y, Zhao X, Qiao Z, et al. Effects of intracoronary pro-urokinase or tirofiban on coronary flow during primary percutaneous coronary ‎intervention for acute myocardial infarction: a multi-center, placebo-controlled, single-blind, randomized clinical trial. Front Cardiovasc Med 2021; 8: 710994.https://doi.org/10.3389/fcvm.2021.710994
6. Sezer M, van Royen N, Umman B, Bugra Z, Bulluck H, Hausenloy DJ, et al. Coronary microvascular injury in reperfused acute myocardial infarction: a view from an integrative perspective. J Am Heart Assoc 2018; 7(21): e009949. https://doi.org/10.1161/JAHA.118.009949
7. Niccoli G, Scalone G, Lerman A, Crea F. Coronary microvascular obstruction in acute myocardial infarction. Eur Heart J 2016; 37(13): 1024-33. https://doi.org/10.1093/eurheartj/ehv484
8. Maznyczka A, Haworth PA. Adjunctive intracoronary fibrinolytic therapy during primary percutaneous coronary intervention. Heart Lung Circ 2021; 30(8): 1140-50. https://doi.org/10.1016/j.hlc.2021.02.016
9. Ziegler M, Wang X, Peter K. Platelets in cardiac ischaemia/reperfusion injury: a promising therapeutic target. Cardiovasc Res 2019; 115(7): 1178-88. https://doi.org/10.1093/cvr/cvz070
10. Ren F, Mu N, Zhang X, Tan J, Li L, Zhang C, et al. Increased platelet-leukocyte aggregates are associated with myocardial no-reflow in patients with ST ‎elevation myocardial infarction. Am J Med Sci 2016; 352(3): 261-6. https://doi.org/10.1016/j.amjms.2016.05.034
11. Tang X, Li R, Jing Q, Liu Y, Liu P. Efficacy and safety of intracoronary versus intravenous administration of tirofiban during percutaneous coronary intervention for acute coronary syndrome: a meta-analysis of randomized controlled trials. PLoS One 2015; 10(6): e0129718. https://doi.org/10.1371/journal.pone.0129718
12. Khosravi A, Sadeghi M, Farsani ES, Danesh M, Heshmat-Ghahdarijani K, Roohafza H, et al. Atherogenic index of plasma: A valuable novel index to distinguish patients with unstable atherogenic plaques. J Res Med Sci 2022; 27. https://doi.org/10.4103/jrms.jrms_590_21
13. McCartney PJ, Eteiba H, Maznyczka AM, McEntegart M, Greenwood JP, Muir DF, et al. Effect of low-dose intracoronary alteplase during primary percutaneous coronary intervention on microvascular obstruction in patients with acute myocardial infarction: a randomized clinical trial. JAMA 2019; 321(1): 56-68.https://doi.org/10.1001/jama.2018.19802
14. Chesebro J, Knatterud G, Roberts R, Borer J, Cohen L, Dalen J, et al. ‎Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: A comparison ‎between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation 1987; 76(1): 142-54.https://doi.org/10.1161/01.CIR.76.1.142
15. Ambrose JA, Torre SR, Sharma SK, Israel DH, Monsen CE, Weiss M, et al. Adjunctive thrombolytic therapy for angioplasty in ischemic rest angina: results of a double-blind randomized pilot study. J Am Coll Cardiol 1992; 20(5): 1197-204. https://doi.org/10.1016/0735-1097(92)90378-Z
16. Schieman G, Cohen B, Kozina J, Erickson J, Podolin R, Peterson K, et al. Intracoronary urokinase for intracoronary thrombus accumulation complicating percutaneous transluminal coronary angioplasty in acute ischemic syndromes. Circulation 1990; 82(6): 2052-60. https://doi.org/10.1161/01.CIR.82.6.2052
17. Morishita H, Hattori R, Acyama T, Kawai C, Yui Y. The intracoronary administration of urokinase following direct PTCA for acute myocardial infarction reduces early restenosis. Am Heart J 1992; 123(5): 1153-6.https://doi.org/10.1016/0002-8703(92)91015-S
18. Ibrahim I, Eldamanhory A, Abdelaziz M, Abdelaziz A. Impact of low-dose intracoronary alteplase infusion after successful primary percutaneous coronary ‎intervention. Int J Clin Cardiol 2019; 6(3): 149.https://doi.org/10.23937/2378-2951/1410149
19. Maznyczka AM, McCartney PJ, Eteiba H, Greenwood JP, Muir DF, Chowdhary S, et al. One-year outcomes after low-dose intracoronary alteplase during primary percutaneous coronary intervention: the T-TIME randomized trial. Circ Cardiovasc Interv 2020; 13(2): e008855. https://doi.org/10.1161/CIRCINTERVENTIONS.119.008855
20. Maznyczka AM, McCartney PJ, Oldroyd KG, Lindsay M, McEntegart M, Eteiba H, et al. Effects of intracoronary alteplase on microvascular function in acute ‎myocardial infarction. J Am Heart Assoc 2020; 9(3): e014066. https://doi.org/10.1161/JAHA.119.014066 
21. Maznyczka AM, McCartney P, Duklas P, McEntegart M, Oldroyd KG, Greenwood JP, et al. Effect of coronary flow on intracoronary alteplase: a prespecified analysis from a randomised trial. Heart 2021; 107(4): 299-312. https://doi.org/10.1136/heartjnl-2020-317828
22. Berry C, Maznyczka AM, McCartney P. Failed myocardial reperfusion during primary PCI: an unmet therapeutic need. EuroIntervention 2019; 14(16): 1628-30. https://doi.org/10.4244/EIJV14I16A279
ARYA Atherosclerosis Journal
Volume 19, Issue 6
November and December 2023
Pages 36-43

Home

Guide for Authors

Submit Manuscript

Reviewers

Contact Us