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2018, vol. 75, iss. 10, pp. 1009-1013
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Factors influencing no-reflow phenomenon in patients with ST-segment myocardial infarction treated with primary percutaneous coronary intervention
Faktori koji utiču na 'no reflow' fenomen kod bolesnika sa infarktom miokarda sa elevacijom ST-segmenta lečenih primarnom perkutanom koronarnom intervencijom
aMilitary Medical Academy, Clinic for Emergency Internal Medicine, Belgrade + University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade bMilitary Medical Academy, Clinic for Emergency Internal Medicine, Belgrade cMilitary Medical Academy, Clinic of Cardiology, Belgrade dClinical Center of Serbia, Belgrade
email: drnemanjadjenic@gmail.com
Abstract
Background/Aim. It is not know which factors influence no-reflow phenomenon after successful primary percutaneous intervention (pPCI) in patients with myocardial infarction with ST elevation (STEMI). The aim of this study was to estimate predictive value of some admission characteristics of patients with STEMI, who underwent pPCI, for the development of no-reflow phenomenon. Worse clinical outcome in patients with no-reflow points to importance of selection and aggressive treatment in a group at high risk. Methods. This was retrospective and partly prospective study which included 491 consecutive patients with STEMI, admitted to a single centre, during the period from 2000 to September 2015, who underwent pPCI. Descriptive characteristics of the patients, presence of classical risk factors for cardiovascular disease, total ischemic time and clinical features at admission were all estimated as predictors for the development of no-reflow phenomenon. No-reflow phenomenon is defined as the presence of thrombolysis in myocardial infarction (TIMI) < 3 coronary flow at the end of the pPCI procedure, or ST-segment resolution by less than 50% in the first hours after the procedure. The significance of the predictive value of some parameters was evaluated by univariate and multivariate regression analysis. In univariate analysis, we used the x2 test and Mann Whitney and Student's t-tests. Results. No-reflow phenomenon was detected in 84 (17.1%) patients (criteria used: TIMI < 3 coronary flow) and in 144 (29.3%) patients (criteria used: ST-sement resolution < 50%). Patients older than 75 years [odds ratio (OR) = 2.53; 95% confidence interval (CI) 1.48-4.33; p = 0.001] and those who had Killip class at admission higher than 1 had increased risk to achieve TIMI-3 flow after pPCI. Killip class higher than 1 (OR 1.59; 95% CI 1.23-2.04; p < 0.001), left anterior descendent artery (LAD) as infarct related artery (IRA) and total ischemic time higher than 4 hour were associated with increased risk to failure of rapid ST segment resolution after pPCI. Conclusion. Older age and Killip class were main predictors of TIMI < 3 flow, and Killip class, LAD as IRA and longer total ischemic time were predictors for the failure of rapid ST segment resolution after pPCI.
Sažetak
Uvod/Cilj. Nedovoljno je poznato koji faktori utiču na nastanak 'no-reflow' fenomena nakon uspešne primarne perkutane intervencije (pPCI) kod bolesnika sa infarktom miokarda sa ST elevacijom (STEMI). Lošiji klinički tok i ishod lečenja kod bolesnika sa 'no-reflow' ukazuje na značaj dobre selekcije i agresivnijeg lečenja u grupi sa visokim rizikom. Cilj studije bio je da se proceni prediktivna vrednost određenih karakteristika na prijemu kod bolesnika sa STEMI koji su lečeni PPCI za razvoj 'no-reflow' fenomena. Metode. Radi se o retrospektivnoj i delom prospektivnoj studiji koja je obuhvatila 491 bolesnika sa STEMI, lečenih na Klinici za uregentnu internu medicinu Vojnomedicinske akademije u Beogradu, u periodu od 2000. godine do septembra 2015. godine pomoću pPCI. Deskriptivne karakteristike bolesnika, postojanje klasičnih faktora rizika za kardiovaskularne bolesti, vreme od početka bola do pPCI, kao i klinički status na prijemu procenjivani su kao mogući prediktori za razvoj fenomena 'no-reflow'. 'No-reflow' fenomen definisan je kao tromboliza kod infarkta miokarda (TIMI) < 3 na kraju pPCI procedure ili rezolucija ST-segmenta za manje od 50% u prvih nekoliko sati nakon procedure. Značaj prisustva i prediktivne vrednosti ovih parametara, procenjivan je univarijantnom i multivarijantnom regresionom analizom. U univarijantnoj analizi, korišćen je x2, Mann Whitney i Studentov t-test. Rezultati. 'No-reflow' fenomen nađen je kod 84 (17,1%) bolesnika (prema kriterijumu TIMI < 3 koronarnog protoka) i kod 144 (29,3%) bolesnika (prema kriteriumu ST - sement rezolucija < 50%). U grupi bolesnika starijih od 75 godina (odds ratio - OR = 2.53; 95% CI 1.48-4.33; p = 0.001), kao i kod onih koji su imali srčanu slabost definisanu kao Killip > 1 [(OR), 1.59; 95% confidence interval (CI) 1.23-2.04; p < 0.001], postojao je statitistički značajno veći rizik za razvoj 'no-reflow' fenomena. Takođe, leva prednja descendentna arterija - left anterior descending (LAD), kao infarktna arterija (IRA) i ukupno ishemijsko vreme duže od četiri sata bili su povezani sa povećanim rizikom za razvoj 'no-reflow' fenomena, praćeno preko parametra izostanak rezolucije ST segmenta za > 50% nakon PPCI. Zaključak. Starije osobe i srčana slabost i Killip > 1 bili su glavni prediktori TIMI < 3 protoka, a Killlip, LAD kao infarktna arterija i duže trajanje ishemije bili su prediktori za sporiju rezoluciju ST-segmenta nakon pPCI.
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