The Role of Intracoronary Epinephrine in Prevention of No-Reflow in STEMI Patients Undergoing Primary PCI

Abstract

P rimary PCI is effective in opening the IRA. However, MVO commonly occurs following PCI, leading 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" and this event is associated with an increased infarct size, reduced recovery of ventricular function, further more this phenomenon is also linked to ventricular arrhythmia, early CHF or even cardiac rupture. There is increasing evidence suggesting a therapeutic potential of IC delivery of vasodilator drugs as epinephrine during primary PCI in prevention and treatment of no- reflow. The aim of the work is to assess the role of IC injection of epinephrine in preventing no-reflow phenomenon and improvement of micro vascular reperfusion in patients with STEMI after primary PCI. This study was conducted on one hundered fifty patients presented to Ain-Shams University hospitals by acute STEMI and were eligble for reperfusion therapy within the period between May 2013 and september 2013. All patients underwent 1ry PCI after diagnostic coronary angiography. IRA was identified and treated using stenting +/- balloon pre-dilatation according to the treating physician, The IC injection of epinephrine at dose of (50-200u), was done just after visualization of the distal run off of the IRA,and before stenting to prevent the occurrence of no-reflow which is defined as < TIMI 3 flow in absence of abrupt closure, high grade stenosis (<50%) and flow limiting dissection. Patients were divided into two groups, 1st group included 75 patients who underwent primary PCI with IC administration of 50 – 200 µg of epinephrine just after visualization of the vessel distal to the site of occlusion and before stenting , and a 2nd group who didn't receive epinephrine before stenting of IRA during primary PCI. The two groups were angiographically compared regarding post procedure TIMI flow grade and MBG. The group of patients who received IC epinephrine during primary PCI showed a statistically significant better post procedure TIMI flow and MBG. Patients with acute STEMI undergoing primary PCI who received IC epinephrine showed higher number of successful ST segment resolution. IC epinephrine injection, the lower grade thrombus burden and direct stenting (no predilation) were predictors of post-procedural TIMI 3 flow but on using multivariate analysis only IC injection of epinephrine and lower grade thrombus burden showed to be independent predictors of TIMI 3 flow. IC epinephrine injection, lower grade thrombus burden, and direct stenting (no predilatation), non anterior MI, shorter DTB and absence of DM were independent predictors of MBG3.