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Predictive factors of in hospital major adverse cardiac events and no reflow phenomenon in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

Sherif Wagdy Ayad

Department of Cardiology, Faculty of Medicine, Alexandria University, Egypt

E-mail : sherifwagdyayad@yahoo.com-

Mohamed Sobhy

Department of Cardiology, Faculty of Medicine, Alexandria University, Egypt

Amr Zaki

Department of Cardiology, Faculty of Medicine, Alexandria University, Egypt

Amr Elkammash

Department of Cardiology, Faculty of Medicine, Alexandria University, Egypt

DOI: 10.15761/JIC.1000129

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Abstract

Objectives

The study is designed to determine the relation between various clinical and laboratory variables and the occurrence of no reflow phenomenon or in hospital MACE (Cardiac death, myocardial infarction, stent thrombosis, or target vessel revascularization) in patients with STEMI undergoing primary PCI.

Background

The investigation of no-reflow phenomenon after primary percutaneous coronary intervention (PPCI) in patients with acute ST-segment–elevation myocardial infarction (STEMI) has therapeutic implications. Patients with no-reflow have more congestive heart failure early after myocardial infarction and demonstrate progressive left ventricular cavity dilatation in the convalescent stage of the infarction.

Methods

We studied prospectively 120 patients with STEMI presenting to Alexandria Main University Hospital (under umbrella of Stent for Life program) and International Cardiac Center (ICC) from April 2013 to October 2013, and eligible for PPCI according to European Society of Cardiology (ESC) guidelines.

Results

The incidence of no reflow was 13.2%, and in hospital MACE was 5%, with cardiac death as the predominant form of in hospital MACE. The group with no reflow and/or in hospital MACE showed significantly older age (62.29 ± 7.90 vs. 56.30 ± 10.34, p=0.014), longer pain to balloon time (15.90 ± 7.87 vs. 6.08 ± 3.82, p˂ 0.001), higher levels of admission random plasma glucose (RPG), neutrophils / lymphocytes (N/L) ratio (8.19 ± 3.05 vs. 5.44 ± 3.53, p˂0.001), and MPV (11.90 ± 2.09 vs. 8.58 ± 1.84, p˂0.001).

Conclusion

Older patient age, longer pain to balloon time, admission hyperglycemia, higher admission N/L ratio and MPV are useful predictive factors for the occurrence of no reflow post PPCI, and/or in hospital MACE. Therefore strong attention should be paid to patients with one or more of these predictive factors, to protect them from the deleterious effects of no reflow, and avoid any of the in hospital MACE.

Key words

mortality, myocardial infarction, no reflow, percutaneous coronary intervention, reperfusion.

Introduction

The phenomenon of no-reflow is defined as inadequate myocardial perfusion through a given segment of the coronary circulation without angiographic evidence of mechanical vessel obstruction [1]. No-reflow has been documented in 30% of patients after thrombolysis or mechanical intervention for acute myocardial infarction [2]. No reflow implies abnormal tissue perfusion and persistent no-reflow is associated with higher incidence of congestive heart failure early after myocardial infarction and demonstrate progressive left ventricular cavity dilatation in the convalescent stage of the infarction [3]. Several key patho-physiological processes, usually in combination, are believed to be responsible for this phenomenon, including distal embolization of atherothrombotic debris, thrombus formation, and endothelial dysfunction of the distal arteriolar and capillary bed, including endothelial desquamation and microcirculatory vasospasm.

Aim of the work

The study is designed to determine the relation between various clinical and laboratory variables and the occurrence of no reflow phenomenon or in hospital MACE (Cardiac death, myocardial infarction, stent thrombosis, or target vessel revascularization) in patients with STEMI undergoing primary PCI.

Methods

The study was conducted on 120 patients with STEMI presenting to Alexandria Main University Hospital (under umbrella of Stent For Life program) and International Cardiac Center (ICC) from April 2013 to October 2013, and eligible for PPCI according to European Society of Cardiology (ESC) guidelines. Informed consent taken from patients. Thorough history taking with special emphasis on risk factors (Age, gender, diabetes, hypertension, smoking, dyslipidemia, family history), history of acute coronary syndromes (ACS) and revascularization, Pain to balloon time, and the presence of pre-infarction angina. Complete clinical examination was done. Admission laboratory investigation included: Complete blood count (CBC) (including mean platelet volume [MPV] and neutrophils/lymphocytes ratio), and random plasma glucose level. All patients had 12 lead electrocardiogram (ECG). The results of the coronary angiography indicating the infarct related artery (IRA), initial TIMI flow in the IRA, and the type of stent used in the PPCI were recorded. The patients were studied according to the presence of various clinical and laboratory variables (age, gender, absence of pre-infarction angina, pain to balloon time, location of the infarction, admission random plasma glucose level and CBC including neutrophils/lymphocytes ratio and MPV, and initial TIMI flow in the IRA), the final TIMI flow after the primary PCI, and the incidence of in hospital MACE [4].

Results

The patients are divided into two groups according to the final TIMI flow after the primary PCI, and the incidence of in hospital MACE as follows: Group A: had a normal flow after the 1ry PCI and did not have In hospital MACE. Group B: had either no reflow after the 1ry PCI or experienced In hospital MACE.

The distribution of the studied groups is shown in Table 1.

Table 1. Distribution of the studied groups

 

No

%

Normal (group A)

99

82.5

No reflow or hospital MACE (group B)

21

17.5

No reflow only

15

71.4

In hospital MACE only ( all in the form of cardiac death)

5

23.8

Both

1

4.8

The demographic data of the two studied groups are shown in table 2.

Table 2. Comparison between the two studied groups according to demographic data

 

 

Group A (n = 99)

Group B (n = 21)

Test of sig.

p

No

%

No

%

Sex

 

 

 

 

 

 

Male

75

75.8

13

61.9

χ2=1.700

0.192

Female

24

24.2

8

38.1

Age

 

 

 

 

Min. – Max.

29.0 – 81.0

44.0 – 78.0

t=2.498

0.014

Mean ± SD

56.30 ± 10.34

62.29 ± 7.90

Median

58.0

62.0

The distribution of the studied groups with respect to pre PPCI variable is shown in tables 3-6.

Table 3. Comparison between the two studied groups according to diabetes, hypertension and smoking

 

Group A (n = 99)

Group B (n = 21)

χ2

p

No

%

No

%

Diabetes

 

 

 

 

 

 

Non diabetic

62

62.6

9

42.9

2.803

MCp=0.094

Diabetic

37

37.4

12

57.1

Insulin

9

9.1

2

9.5

-

-

OHD

28

28.3

10

47.6

Hypertension

48

48.5

7

33.3

1.602

0.206

Smoking

 

 

 

 

 

 

Non smoker

43

43.4

11

52.4

0.560

0.454

Smoker

52

52.5

9

42.9

0.648

0.421

Ex-smoker

4

4.0

1

4.8

0.023

FEp =1.000

Dyslipidemia

54

54.5

15

71.4

2.021

0.155

Family History

17

17.2

2

9.5

0.760

FEp=0.521

Previous ACS

19

19.2

3

14.3

0.279

FEp=0.762

Absence of preinfarction angina

56

56.6

15

71.4

1.584

0.208

Table 4. Comparison between the two studied groups according to SBP, DBP and pulse

 

Group A (n = 99)

Group B (n = 21)

t

p

SBP

 

 

 

 

Min. – Max.

50.0 – 200.0

70.0 – 160.0

1.971

0.051

Mean ± SD

129.29 ± 27.93

116.67 ± 19.32

Median

130.0

120.0

DBP

 

 

 

 

Min. – Max.

30.0 – 120.0

40.0 – 90.0

1.870

0.064

Mean ± SD

81.06 ± 15.62

74.29 ± 12.07

Median

80.0

70.0

Pulse

 

 

 

 

Min. – Max.

41.0 – 120.0

60.0 – 130.0

0.069

0.945

Mean ± SD

84.56 ± 16.33

84.29 ± 15.69

Median

80.0

88.0

Table 5. Comparison between the two studied groups according to ECG.

 

Group A
(n = 99)

Group B

(n = 21)

χ2

p

No

%

No

%

ECG

 

 

 

 

 

 

Anterior MI

72

72.7

14

66.7

0.313

0.576

Lateral MI

6

6.1

2

9.5

0.334

FEp=0.628

Inferior MI

21

21.2

6

28.6

0.538

FEp=0.565

Right MI

8

8.1

1

4.8

0.275

FEp=1.000

Posterior MI

7

7.1

2

9.5

0.150

FEp=0.656

Table 6. Comparison between the two studied groups according to pain to balloon time.

 

Group A
(n = 99)

Group B

(n = 21)

Z

p

Pain to balloon time

 

 

 

 

Min. – Max.

1.0 – 19.0

1.0 – 30.0

4.999*

<0.001*

Mean ± SD

6.08 ± 3.82

15.90 ± 7.87

Median

5.0

17.0

The distribution of the studied groups with respect to laboratory results, angiographic findings and procedural aspects is shown in tables 7-9.

Table 7. Comparison between the two studied groups according to laboratory results (on admission)

 

Group A
(n = 99)

Group B

(n = 21)

Test of sig.

p

Plasma glucose

 

 

 

 

Min. – Max.

84.0 – 442.0

104.0 – 440.0

Z = 3.377*

0.001*

Mean ± SD

186.38 ± 84.65

275.29 ± 104.11

Median

150.0

280.0

N/L ratio

 

 

 

 

Min. – Max.

1.20 – 24.0

2.80 – 13.0

Z = 3.665

<0.001*

Mean ± SD

5.44 ± 3.53

8.19 ± 3.05

Median

4.50

8.0

MPV

 

 

 

 

Min. – Max.

5.0 – 13.0

5.90 – 15.0

t = 7.320*

<0.001*

Mean ± SD

8.58 ± 1.84

11.90 ± 2.09

Median

8.20

12.20

Table 8. Comparison between the two studied groups according to infarct related artery

 

Group A
(n = 99)

Group B

(n = 21)

χ2

p

No

%

No

%

Infarct related artery

 

 

 

 

 

 

LAD

70

70.7

14

66.7

0.135

0.714

D1

5

5.1

0

0.0

-

-

CX

2

2.0

2

9.5

3.027

FEp =0.141

OM

1

1.0

0

0.0

-

-

RCA

20

20.2

5

23.8

0.137

FEp =0.769

PDA

1

1.0

0

0.0

0.214

FEp = 1.000

Table 9. Comparison between the two studied groups according to initial TIMI flow and Type of stent used

 

Group A
(n = 99)

Group B

(n = 21)

Test of sig.

p

No

%

No

%

Initial TIMI flow

 

 

 

 

 

 

0

87

87.6

19

90.4

Z = 1.844

0.065

1

25

25.3

1

4.8

2

5

5.1

1

4.8

Type of stent used

 

 

 

 

 

 

No stent

0

0.0

2

9.5

χ2 = 9.588*

FEp =0.029*

BMS

51

51.5

12

57.1

χ2 = 0.220

0.810

DES

48

48.5

7

33.3

χ2 = 1.602

0.236

Discussion

A lot of researchers tried to study variables predicting the incidence of no reflow and/or in hospital MACE in STEMI patients undergoing PPCI. Ndrepepa G et al. [5], found that initial TIMI 0 flow in the infarct-related artery (P˂0.001), initial perfusion defect (P˂0.03), and previous myocardial infarction (P˂0.013) as independent predictors of no reflow. Akpek M et al. [6], reported that N/L ratio > 3.3 predicted no reflow with 74% sensitivity, and 83% specificity, and that high N/L ratio is independent predictor of no reflow, and in hospital MACE. Iwakura K et al. [7], found that admission hyperglycemia ( >160 mg/dl) was an independent prognostic factor for no reflow, along with older age, male gender, absence of pre-infarction angina, complete occlusion of the culprit lesion, and anterior STEMI. Huczek Z et al. [8], found that high mean platelet volume (>10.3 fl) is a strong, independent predictor of no reflow in STEMI patients undergoing PPCI. In our study, we found that the groups with no reflow or in hospital MACE showed significantly older age, longer pain to balloon time, and higher levels of admission random plasma glucose (RPG), N/L ratio, and MPV.

Conclusion

Older patient age, longer pain to balloon time, admission hyperglycemia, higher admission N/L ratio and MPV are useful predictive factors for the occurrence of no reflow post PPCI, and/or in hospital MACE. Therefore strong attention should be paid to patients with one or more of these predictive factors, to protect them from the deleterious effects of no reflow, and avoid any of the in hospital MACE.

References

  1. Morishima I, Sone T, Okumura K, Tsuboi H, Kondo J, et al. (2000) Angiographic no-reflow phenomenon as a predictor of adverse long-term outcome in patients treated with percutaneous transluminal coronary angioplasty for first acute myocardial infarction. J Am Coll Cardiol36: 1202-1209. [Crossref]
  2. Abbo KM, Dooris M, Glazier S, O'Neill WW, Byrd D, et al. (1995) Features and outcome of no-reflow after percutaneous coronary intervention. Am J Cardiol 75: 778-782. [Crossref]
  3. Bonz AW, Lengenfelder B, Strotmann J, Held S, Turschner O, et al. (2002) Effect of additional temporary glycoprotein IIb/IIIa receptor inhibition on troponin release in elective percutaneous coronary interventions after pretreatment with aspirin and clopidogrel (TOPSTAR trial). J Am Coll Cardiol 40: 662-668. [Crossref]
  4. Rezkella SH, Kloner RA (2002) No-reflow phenomenon. Circulation 105: 656-662. [Crossref]
  5. Ndrepepa G, Tiroch K, Keta D, Fusaro M, Seyfarth M, et al. (2010) Predictive Factors and Impact of No Reflow After Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction. Circ Cardiovasc Interv 3: 27-33. [Crossref]
  6. Akpek M, Sahin O, Elick D, Kaya MG (2013) The association of neutrophils/lymphocytes ratio with coronary flow and in hospital MACE in patients with STEMI undergoing primary PCI. Eur Heart J 27: 534 –539.
  7. Iwakura K, Ito H, Ikushima M, Kawano S, Okamura A, et al. (2003) Association between hyperglycemia and the no-reflow phenomenon in patients with acute myocardial infarction. J Am Coll Cardiol 41: 1–7. [Crossref]
  8. Huczek Z, Kochman J, Filipiak KJ, Horszczaruk GJ, Grabowski M, et al. (2005) Mean platelet volume on admission predicts impaired reperfusion and long-term mortality in acute myocardial infarction treated with primary percutaneous coronary intervention. J Am Coll Cardiol 46: 284 –290. [Crossref]

Editorial Information

Editor-in-Chief

Massimo Fioranelli
Guglielmo Marconi University

Article Type

Research Article

Publication history

Received: May 23, 2015
Accepted: July 24, 2015
Published: July 27, 2015

Copyright

©2015 Ayad SW. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Ayad SW, Sobhy M, Zaki A, Elkammash A (2015) Predictive factors of in hospital major adverse cardiac events and no reflow phenomenon in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention. J Integr Cardiol, 1: DOI: 10.15761/JIC.1000129

Corresponding author

Sherif Wagdy Ayad

Department of Cardiology, Faculty of Medicine, Alexandria University, Egypt

E-mail : sherifwagdyayad@yahoo.com-

Table 1. Distribution of the studied groups

 

No

%

Normal (group A)

99

82.5

No reflow or hospital MACE (group B)

21

17.5

No reflow only

15

71.4

In hospital MACE only ( all in the form of cardiac death)

5

23.8

Both

1

4.8

The demographic data of the two studied groups are shown in table 2.

Table 2. Comparison between the two studied groups according to demographic data

 

 

Group A (n = 99)

Group B (n = 21)

Test of sig.

p

No

%

No

%

Sex

 

 

 

 

 

 

Male

75

75.8

13

61.9

χ2=1.700

0.192

Female

24

24.2

8

38.1

Age

 

 

 

 

Min. – Max.

29.0 – 81.0

44.0 – 78.0

t=2.498

0.014

Mean ± SD

56.30 ± 10.34

62.29 ± 7.90

Median

58.0

62.0

The distribution of the studied groups with respect to pre PPCI variable is shown in tables 3-6.

Table 3. Comparison between the two studied groups according to diabetes, hypertension and smoking

 

Group A (n = 99)

Group B (n = 21)

χ2

p

No

%

No

%

Diabetes

 

 

 

 

 

 

Non diabetic

62

62.6

9

42.9

2.803

MCp=0.094

Diabetic

37

37.4

12

57.1

Insulin

9

9.1

2

9.5

-

-

OHD

28

28.3

10

47.6

Hypertension

48

48.5

7

33.3

1.602

0.206

Smoking

 

 

 

 

 

 

Non smoker

43

43.4

11

52.4

0.560

0.454

Smoker

52

52.5

9

42.9

0.648

0.421

Ex-smoker

4

4.0

1

4.8

0.023

FEp =1.000

Dyslipidemia

54

54.5

15

71.4

2.021

0.155

Family History

17

17.2

2

9.5

0.760

FEp=0.521

Previous ACS

19

19.2

3

14.3

0.279

FEp=0.762

Absence of preinfarction angina

56

56.6

15

71.4

1.584

0.208

Table 4. Comparison between the two studied groups according to SBP, DBP and pulse

 

Group A (n = 99)

Group B (n = 21)

t

p

SBP

 

 

 

 

Min. – Max.

50.0 – 200.0

70.0 – 160.0

1.971

0.051

Mean ± SD

129.29 ± 27.93

116.67 ± 19.32

Median

130.0

120.0

DBP

 

 

 

 

Min. – Max.

30.0 – 120.0

40.0 – 90.0

1.870

0.064

Mean ± SD

81.06 ± 15.62

74.29 ± 12.07

Median

80.0

70.0

Pulse

 

 

 

 

Min. – Max.

41.0 – 120.0

60.0 – 130.0

0.069

0.945

Mean ± SD

84.56 ± 16.33

84.29 ± 15.69

Median

80.0

88.0

Table 5. Comparison between the two studied groups according to ECG.

 

Group A
(n = 99)

Group B

(n = 21)

χ2

p

No

%

No

%

ECG

 

 

 

 

 

 

Anterior MI

72

72.7

14

66.7

0.313

0.576

Lateral MI

6

6.1

2

9.5

0.334

FEp=0.628

Inferior MI

21

21.2

6

28.6

0.538

FEp=0.565

Right MI

8

8.1

1

4.8

0.275

FEp=1.000

Posterior MI

7

7.1

2

9.5

0.150

FEp=0.656

Table 6. Comparison between the two studied groups according to pain to balloon time.

 

Group A
(n = 99)

Group B

(n = 21)

Z

p

Pain to balloon time

 

 

 

 

Min. – Max.

1.0 – 19.0

1.0 – 30.0

4.999*

<0.001*

Mean ± SD

6.08 ± 3.82

15.90 ± 7.87

Median

5.0

17.0

The distribution of the studied groups with respect to laboratory results, angiographic findings and procedural aspects is shown in tables 7-9.

Table 7. Comparison between the two studied groups according to laboratory results (on admission)

 

Group A
(n = 99)

Group B

(n = 21)

Test of sig.

p

Plasma glucose

 

 

 

 

Min. – Max.

84.0 – 442.0

104.0 – 440.0

Z = 3.377*

0.001*

Mean ± SD

186.38 ± 84.65

275.29 ± 104.11

Median

150.0

280.0

N/L ratio

 

 

 

 

Min. – Max.

1.20 – 24.0

2.80 – 13.0

Z = 3.665

<0.001*

Mean ± SD

5.44 ± 3.53

8.19 ± 3.05

Median

4.50

8.0

MPV

 

 

 

 

Min. – Max.

5.0 – 13.0

5.90 – 15.0

t = 7.320*

<0.001*

Mean ± SD

8.58 ± 1.84

11.90 ± 2.09

Median

8.20

12.20

Table 8. Comparison between the two studied groups according to infarct related artery

 

Group A
(n = 99)

Group B

(n = 21)

χ2

p

No

%

No

%

Infarct related artery

 

 

 

 

 

 

LAD

70

70.7

14

66.7

0.135

0.714

D1

5

5.1

0

0.0

-

-

CX

2

2.0

2

9.5

3.027

FEp =0.141

OM

1

1.0

0

0.0

-

-

RCA

20

20.2

5

23.8

0.137

FEp =0.769

PDA

1

1.0

0

0.0

0.214

FEp = 1.000

Table 9. Comparison between the two studied groups according to initial TIMI flow and Type of stent used

 

Group A
(n = 99)

Group B

(n = 21)

Test of sig.

p

No

%

No

%

Initial TIMI flow

 

 

 

 

 

 

0

87

87.6

19

90.4

Z = 1.844

0.065

1

25

25.3

1

4.8

2

5

5.1

1

4.8

Type of stent used

 

 

 

 

 

 

No stent

0

0.0

2

9.5

χ2 = 9.588*

FEp =0.029*

BMS

51

51.5

12

57.1

χ2 = 0.220

0.810

DES

48

48.5

7

33.3

χ2 = 1.602

0.236