• Users Online: 353
  • Print this page
  • Email this page


 
 
Table of Contents
RESEARCH ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 4  |  Page : 121-124

Efficacy of sodium nitroprusside combined with verapamil in the treatment of no-reflow during coronary interventional therapy


Department of Cardiology, Jinxiang Hospital Affiliated to Jining Medical College, Jining, Shandong Province, China

Date of Submission21-Nov-2019
Date of Decision05-Dec-2019
Date of Acceptance06-Dec-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Jianjun Dai
Department of Cardiology, Jinxiang Hospital Affiliated to Jining Medical College, Jining, Shandong Province
China
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cp.cp_24_19

Get Permissions

  Abstract 


Context: The possible pathophysiological mechanisms of no-reflow are ischemic injury, reperfusion injury, endothelial injury, distal thromboembolism, etc., Moreover, no-reflow can also remarkably increase the risks of acute myocardial infarction, heart failure, malignant arrhythmia, pericardial tamponade, and even death. Aims: The aim was to evaluate the efficacy of sodium nitroprusside combined with verapamil in the treatment of no-reflow. Settings and Design: From December 2016 to December 2017, 100 patients with no-reflow during coronary intervention in our hospital were selected and randomly divided into two groups: treatment group (50 cases) treated by sodium nitroprusside combined with verapamil and control group (50 cases) treated with sodium nitroprusside treatment alone. Subjects and Methods: The blood flow grading of the two groups according to a thrombolysis test in myocardial infarction (TIMI) was compared and analyzed, and the incidence of cardiovascular adverse events was compared in the 6-month period following the operation. Statistical Analysis Used: SPSS 17.0 (IBM, America) was employed in all calculations. Quantitative data were expressed as mean ± standard deviation, and intergroup comparison was calculated using a two-tailed t-test. Qualitative data were presented in percentages, and intergroup comparison was performed with Chi-square test.P < 0.05 was considered statistically significant. Results: The patients with TIMI Grade III blood flow in the treatment group were significantly more than those in the control group after medication, and the difference was statistically significant (P < 0.05). In the following 6-month period after the operation, the incidence of cardiovascular adverse events in the treatment group was 6.00% (3/50), which was lower than that in the control group 18.0% (9/50), with statistically significant difference (P < 0.05). Conclusions: Sodium nitroprusside combined with verapamil can significantly improve the no-reflow following coronary interventional therapy and reduce the incidence of adverse cardiovascular events.

Keywords: Coronary intervention, no-reflow, sodium nitroprusside, verapamil


How to cite this article:
Gao C, Wang L, Li L, Shao P, Li F, Kang C, Dai J. Efficacy of sodium nitroprusside combined with verapamil in the treatment of no-reflow during coronary interventional therapy. Cardiol Plus 2019;4:121-4

How to cite this URL:
Gao C, Wang L, Li L, Shao P, Li F, Kang C, Dai J. Efficacy of sodium nitroprusside combined with verapamil in the treatment of no-reflow during coronary interventional therapy. Cardiol Plus [serial online] 2019 [cited 2020 May 27];4:121-4. Available from: http://www.cardiologyplus.org/text.asp?2019/4/4/121/274574




  Introduction Top


No-reflow of the coronary artery refers to Grade 0–I blood flow according to the thrombolysis test in myocardial infarction (TIMI), which is determined after dredging a severely stenosed or occluded coronary artery during coronary intervention (percutaneous coronary intervention [PCI]). TIMI flow Grade II can also be referred to as slow flow of coronary arteries. On occasion, when TIMI flow of epicardial coronary artery reaches Grade III but with no reperfusion in cardiac myocytes, it can also be categorized as “no-reflow” or “slow flow.”[1],[2] The possible pathophysiological mechanisms of no-reflow are ischemic injury, reperfusion injury, endothelial injury, distal thromboembolism, etc., Moreover, no-reflow remarkably increases the risks of acute myocardial infarction, heart failure, malignant arrhythmia, pericardial tamponade, and even death. Currently, drugs that are available to prevent and treat “no-reflow” of coronary arteries include adenosine, sodium nitroprusside, verapamil, nitroglycerin, and tirofiban. In this study, sodium nitroprusside combined with verapamil was used to treat patients with no-reflow of coronary arteries to observe the effect on blood flow and patient prognosis.


  Subjects and Methods Top


From December 2016 to December 2017, a total of 960 cases (180 cases of acute ST-segment elevation myocardial infarction, 580 cases of acute coronary syndrome, and 200 cases of stable angina pectoris) were treated by coronary intervention in our hospital. A total of 105 cases (50 cases of acute ST-segment elevation myocardial infarction, 52 cases of acute coronary syndrome, and 3 cases of stable angina pectoris) were classified as no-reflow. The incidence of no-reflow was 11.9% (27.8% acute ST-segment elevation myocardial infarction, 8.97% acute coronary syndrome, and 1.50% stable angina pectoris) [Figure 1], [Figure 2], [Figure 3]. Inclusion criteria: TIMI had Grade 0–1 blood flow after balloon expansion or stent release during coronary interventional therapy, which represented a total of 100 cases [Figure 4].
Figure 1: Left anterior descending stenosis

Click here to view
Figure 2: Stent release

Click here to view
Figure 3: Left anterior descending no-flow

Click here to view
Figure 4: Injected with sodium nitroprusside and verapamil

Click here to view


Exclusion criteria

Patients with cardiogenic shock or heart failure during coronary intervention (Killip level IV), which had a total of five cases. Randomized controlled trials were conducted on enrolled patients. A random number table method was used to divide the two groups: the treatment group (50 cases) treated by sodium nitroprusside combined with verapamil and the control group (50 cases) treated with only sodium nitroprusside. The treatment group consisted of 25 males and 25 females, aged 59–76 years, with an average age of 67.2 ± 5.14 years. TIMI grading after no-reflow included Grade 0 in 28 cases and Grade I in 22 cases. In the control group, there were 26 males and 24 females, aged 58–78 years, with an average age of 66.3 ± 7.14 years. After no reflow, TIMI grading was Grade 0 in 26 cases and Grade I in 24 cases. There was no statistically significant difference in gender, age, TIMI grade, or other basic clinical data between the two groups (P > 0.05).

Before the operation, both groups were given 180-mg ticagrelor and 300-mg aspirin orally. When no-reflow occurred during coronary intervention, the patients in the treatment group were promptly injected with 200-μg sodium nitroprusside and 200-μg verapamil into the distal segment of coronary arteries through a microcatheter. The control group was injected with 200-μg sodium nitroprusside in the same time frame and location. Coronary angiography was performed 2 min after the injection, and TIMI blood flow was closely monitored. Both groups received continuous intravenous pumping of 0.15μg/kg/min tirofiban for 24 h after the operation.

Observational indexes

(1) TIMI blood flow grading was compared between the two groups after medication. Grade 0: no blood flow filling and no blood flow in the distal segment of occluded vessels; Grade I: partial passing of the contrast agent, but no full filling in the distal segment of stenosis; Grade II: full filling in the distal segment of stenosis, but with slow development and slow elimination of the contrast agent; and Grade III: full filling in the distal segment of stenosis, as well as rapid filling and elimination of the contrast agent. (2) The adverse cardiovascular events, such as angina pectoris, myocardial infarction, and left heart failure, were compared at follow-ups in the 6-month period following the operation.


  Results Top


Thrombolysis test in myocardial infarction classification of two groups after medication

After using sodium nitroprusside and verapamil in the treatment group, there were 0 case (0.00%) of TIMI 0, 0 case (0.00%) of TIMI I, 10 cases (20.0%) of TIMI II, and 40 cases (80.0%) of TIMI III. In addition, after the application of sodium nitroprusside in the control group, there were 0 case (0.00%) of TIMI 0, 1 case (2.00%) of TIMI I, 22 cases (44.0%) of TIMI II, and 28 cases (56.0%) of TIMI III. There were statistically significantly more patients classified as TIMI III in the treatment group than in the control group (80.0 vs. 56.0, P < 0.05) [Table 1].
Table 1: Thrombolysis test in myocardial infarction classification of two groups after medication

Click here to view


Comparison of incidence of cardiovascular adverse events between the two groups

There were three follow-ups, including 1 month, 3 months, and 6 months after the operation. The follow-up rate was 100% and appointments consisted of measuring clinical symptoms, signs, routine blood lipid and glucose, liver and kidney function, electrocardiogram, cardiac color Doppler ultrasound, etc. There were two cases of angina pectoris, one case of myocardial infarction, and 0 case of left heart failure in the treatment group. There were five cases of angina pectoris, two cases of myocardial infarction, and two cases of left heart failure in the control group. The incidence of adverse events in the treatment group (three cases) was statistically significantly lower than that in the control group (nine cases; 6.00% vs. 18.0%, P < 0.05) [Table 2].
Table 2: Comparison of incidence of cardiovascular adverse events between the two groups

Click here to view



  Discussion Top


There are numerous risk factors for no-reflow of coronary arteries. For instance, it is clinically believed that thrombotic lesions, emergency PCI treatment, prior myocardial infarction, and coronary artery bypass grafting have predictive significance for no-reflow,[3],[4] whereas coronary artery lesions such as ulcers, thrombosis, calcification, and lesions of saphenous vein graft may indicate higher risk of no-reflow. Furthermore, during coronary intervention, operations such as multiple balloon dilatation, posterior dilatation of high-pressure balloon, prolonged length of implanted stent, and rotational atherectomy can also promote the precipitation of atherosclerotic plaque debris, thereby leading to no-reflow. Therefore, in clinical practice, more attention should be paid to the standardized operation during surgeries for high-risk patients who are prone to develop no-reflow vascular lesion.

With the occurrence of no-reflow, especially when the flow in coronary artery is only TIMI 0–I Grade, the injected drugs through guided catheters may not be effective for their failure to reach the coronary microcirculation due to lack of blood flow usually. In order to solve this issue, sodium nitroprusside, verapamil, nitroglycerin, tirofiban, and other drugs can be injected to the distal end of related arteries by microcatheters or thrombus aspiration catheters to promote rapid release of drug effect generally.[5],[6]

Verapamil, a calcium antagonist, can be applied to effectively reverse coronary microvascular spasm, inhibit calcium overload, reduce oxygen-free radical generation, protect heart muscle, and improve microcirculation function to relieve no-reflow. Verapamil can be applied intermittently and repeatedly with 100–200 μg per application. It is reported that no-reflow of coronary arteries can be remarkably improved by verapamil at the maximum dose of 1 mg. Occasionally, this results in heart rate drop or transient atrioventricular block, and physicians of patients with pump failure should pay attention to the negative inotropic activity of these drugs. Other calcium antagonists such as diltiazem and nicardipine can also exert such similar effects. Sodium nitroprusside is a nitric oxide donor, which has powerful vasodilating effect and can improve vascular endothelial function. In this article, TIMI flow was improved by applying sodium nitroprusside combined with verapamil when compared with that using sodium nitroprusside alone, and the incidence of adverse cardiovascular events was also lower in the period of follow-up after surgery.[7],[8]

Results of this study indicate that sodium nitroprusside combined with verapamil is a more effective treatment for no-reflow of coronary arteries than sodium nitroprusside alone. However, for the limited samples in this study, there may be certain bias between the research results and the real cases. In addition, enrolled patients were only followed up intraoperatively and for 6 months postoperatively in this study, without a long-term follow-up. The long-term effect of the studied drugs requires further follow-ups in future.


  Conclusions Top


Sodium nitroprusside combined with verapamil can significantly improve the no-reflow following coronary interventional therapy and reduce the incidence of adverse cardiovascular events.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abdelaziz HK, Elkilany W, Khalid S, Sabet S, Saad M. Efficacy and safety of intracoronary verapamil versus sodium nitroprusside for the prevention of microvascular obstruction during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Coron Artery Dis 2017;28:11-6.  Back to cited text no. 1
    
2.
Latt H, Aung S, Kyaw K, Seher R. Coronary artery ectasia presenting with acute inferior wall myocardial infarction in a young adult. J Community Hosp Intern Med Perspect 2017;7:262-4.  Back to cited text no. 2
    
3.
Kloner RA. The importance of no-reflow/microvascular obstruction in the STEMI patient. Eur Heart J 2017;38:3511-3.  Back to cited text no. 3
    
4.
de Waha S, Patel MR, Granger CB, Ohman EM, Maehara A, Eitel I, et al. Relationship between microvascular obstruction and adverse events following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: An individual patient data pooled analysis from seven randomized trials. Eur Heart J 2017;38:3502-10.  Back to cited text no. 4
    
5.
Schram HC, Hemradj VV, Hermanides RS, Kedhi E, Ottervanger JP; Zwolle Myocardial Infarction Study Group. Coronary artery ectasia, an independent predictor of no-reflow after primary PCI for ST-elevation myocardial infarction. Int J Cardiol 2018;265:12-7.  Back to cited text no. 5
    
6.
Durante A. Role of no reflow and microvascular obstruction in the prognostic stratification of STEMI patients. Anatol J Cardiol 2018;19:346-9.  Back to cited text no. 6
    
7.
Pontone G, Andreini D, Guaricci AI, Guglielmo M, Baggiano A, Muscogiuri G, et al. Association between haptoglobin phenotype and microvascular obstruction in patients with STEMI: A cardiac magnetic resonance study. JACC Cardiovasc Imaging 2019;12:1007-17.  Back to cited text no. 7
    
8.
Campo G, Gallo F, Bugani G, Pavasini R, Fineschi M. How the functional assessment of culprit and non-culprit lesions may improve stratification and treatment of STEMI patients. Minerva Cardioangiol 2018;66:442-51.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Subjects and Methods
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed580    
    Printed61    
    Emailed0    
    PDF Downloaded84    
    Comments [Add]    

Recommend this journal