Pharmaceutical Interventions for the Management of No-Reflow

Tim A. Fischell, MD

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

In This Article


Nicardipine possesses a number of attributes suggesting particular utility for reversal and/or prevention of no-reflow.[49] It is a dihydropyridine calcium-channel antagonist with relatively selective coronary vascular effects, producing a marked increase in coronary blood flow in vascular smooth muscle with minimal direct myocardial depressant activity.[50,51] In a comparative study with IC diltiazem or verapamil, IC nicardipine achieved significantly more prolonged coronary vasodilation and a significantly greater mean increase over baseline coronary flow velocity than either nondihydropyridine.[52]

In a retrospective study, IC nicardipine successfully reversed no-reflow associated with PCI of native vessels or grafts and restored TIMI 3 flow in 71/72 patients.[53] TIMI flow grade pre- and post-treatment was 1.65 ± 0.53 and 2.97 ± 0.24, respectively (p <0.001), while frame counts decreased from 57 ± 40 at the time of no-reflow to 15 ± 12 after nicardipine (p <0.001). More recently, prophylactic intragraft nicardipine followed immediately by direct stenting of SVGs without mechanical distal protection in a series of 68 elective patients dramatically reduced the incidence of no-reflow. Transient no-reflow was observed in 2/83 graft interventions (2.4%), an incidence comparable to elective interventions in native vessels. The overall rate of 30-day major adverse cardiac events in this study was at least as low as historical data from trials evaluating different mechanical distal protection systems, suggesting a potential pharmacologic alternative or adjunct to mechanical distal protection.[31]


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