Pharmaceutical Interventions for the Management of No-Reflow

Tim A. Fischell, MD

J Invasive Cardiol. 2008;20(7):374-379. 

In This Article


The emergence of no-reflow as a frequent complication of PCI, particularly when the intervention involves a degenerated vein graft, suggests that improving the integrity of microvascular flow should be as much a focus of reperfusion therapy as opening the culprit vessel. The restoration of patency in large-caliber vessels should not be confused with restoration of microvascular flow. The challenge facing interventional cardiology is to identify adjunctive methods to optimize robust reflow into the myocardium.

The no-reflow phenomenon reflects the structural, neurohumoral and metabolic tumult associated with cardiac ischemia and its reversal. Many mechanisms are implicated in the development of no-reflow, and optimal therapy is unclear. It remains to be determined whether individual agents or combinations of medications or devices addressing specific targets will provide clinically relevant benefits. For selected patients undergoing PCI, GP IIb/IIIa antagonists, distal protection and vasodilating drugs may be reasonable adjuncts to maximize periprocedural microvascular integrity. For patients in whom the no-reflow syndrome develops, prompt administration of a vasodilating medication such as adenosine, nitroprusside, verapamil or nicardipine may represent the most potent and practical therapeutic intervention to reperfuse myocardium.


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