Pharmaceutical Interventions for the Management of No-Reflow

Tim A. Fischell, MD

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

In This Article


A retrospective study demonstrated that IC verapamil improved TIMI flow grade in 89% of no-reflow patients following PCI and markedly improved TFC (from 91 ± 56 to 38 ± 21 frames, p <0.001).[10] Pretreatment verapamil administered to 10 patients undergoing PCI of saphenous vein grafts was associated with a nonsignificantly reduced incidence of no-reflow vs. no pretreatment. Flow rate in the vessel as assessed by TFC was significantly faster in pretreated patients (p = 0.016), suggestive of increased perfusion and reduced downstream resistance.45 In a prospective investigation, intragraft verapamil for no-reflow associated with angioscopy, extraction atherectomy, balloon angioplasty or stent implantation in degenerated SVG lesions resulted in significant improvement in flow in all instances (TIMI flow grade 1.4 ± 0.8 before, to 2.8 ± 0.5 after verapamil, p <0.001). TIMI 3 flow was reestablished in 88% of episodes. In contrast, intragraft nitroglycerin alone had no relevant effects on TIMI flow.[46] IC verapamil reversed no-reflow in a consecutive series of 212 direct or rescue stent deployment for infarction. Twenty-three (10.8%) patients developed no-reflow. Verapamil reduced TFC from 56 ± 9 frames to 24 ± 4, a significant change versus controls (p <0.001). TIMI flow grade 3 was restored in 65% of instances. Verapamil was associated with intermittent atrioventricular block in 3 patients.[47] Finally, in a randomized, comparative, placebo-controlled study of IC verapamil, adenosine or placebo administered immediately after PCI, both verapamil and adenosine significantly improved coronary flow, although 18% of patients receiving verapamil developed heart block.[35] Diltiazem. A retrospective series of 24 case reports indicated that IC diltiazem may be effective in reversing no-reflow associated with PCI of native arteries or grafts. Fifteen of the 24 patients in this series were severely symptomatic due to TIMI flow grade 0 or 1, requiring support with aramine, atropine or temporary pacing, and showed no improvement with IC nitroglycerin. Administration of IC diltiazem boluses led to prompt clinical and angiographic improvement in flow grade in most patients and was well tolerated.[48]


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