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Presenter Disclosure Information. Atul Aggarwal, MD Incidence, Predictors and In-hospital Outcomes of No Reflow Phenomenon during Percutaneous Coronary Intervention for Acute Myocardial Infarction . DISCLOSURE INFORMATION: The following relationships exist related to this presentation

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  1. Presenter Disclosure Information Atul Aggarwal, MD Incidence, Predictors and In-hospital Outcomes of No Reflow Phenomenon during Percutaneous Coronary Intervention for Acute Myocardial Infarction DISCLOSURE INFORMATION: The following relationships exist related to this presentation Atul Aggarwal: Speakers Bureau – The Medicines Company (Modest); Stock options None; Consults for None; Research support - None 1

  2. Incidence, Predictors and In-hospital Outcomes of No Reflow Phenomenon during Percutaneous Coronary Intervention for Acute Myocardial Infarction Atul Aggarwal,1 Fang-shu Ou,2 Lloyd W. Klein,3 John S. Rumsfeld,4 Matthew T. Roe,2 Tracy Y. Wang,2 on behalf of American College of Cardiology National Cardiovascular Data Registry (ACC NCDR) Comprehensive Cardiovascular Medical Group, Bakersfield, CA,1 Duke Clinical Research Institute, Durham, NC,2 Rush Medical College, Chicago, IL3 and VA Medical Center, Denver, CO4 2

  3. Background • No reflow phenomenon is poorly understood complication of percutaneous coronary intervention (PCI) when reduced coronary blood flow persists despite intraprocedural removal of epicardial occlusion • No reflow may occur due to microvascular obstruction from response to inflammation, injury from ischemia reperfusion or endothelial swelling • Knowledge about no-reflow based on small studies (incidence during PCI=0.6-3.2%; incidence during PCI for acute MI=11-41%) 3

  4. Study Objectives 1. Determine incidence of no reflow during native vessel PCI for acute MI 2. Examine clinical factors associated with development of no reflow 3. Assess clinical outcomes associated with no reflow 4

  5. Study Population • Patients undergoing PCI for acute STEMI and NSTEMI in NCDR from 01/01/2004-09/05/2008 were evaluated (n=305,694 across 886 hospitals) • Patients with SVG interventions excluded • 22 patients with missing data about no reflow also excluded • Final study population comprised of 291,380 patients from 886 sites 5

  6. EventDefinitions • No reflow phenomenon defined in NCDR as transient cessation of blood flow in epicardial coronary artery during PCI • Definition of no reflow constant since inception of registry • No reflow phenomenon ascertained and reported by individual sites with no central angiographic core laboratory confirmation or independent adjudication of events 6

  7. Results 291,380 AMI patients undergoing PCI 6553 (2.3%) developed no reflow STEMI NSTEMI n=182,467 n=108,913 4895 (2.7%) 1058 (1.0%) No reflow No reflow 7

  8. Table 1. Clinical Characteristics Baseline Characteristics 8

  9. Factors Independently Associated with No-Reflow by Multivariate Analysis Adjusted OR 95% CI Chi square All P values < 0.001 Associated with No Reflow Odds ratio 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 9

  10. In-Hospital Angiographic Outcomes • Lesion success rates = establishment of post procedure TIMI 3 flow with residual stenosis<25% with stent or <50% without stent • No reflow significantly associated with unsuccessful lesion outcome (adjusted Odds Ratio = 4.70, 95% CI 4.28-5.17, p<0.001) in multivariable analysis 10

  11. In-Hospital Clinical Outcomes P<0.0001 for each outcome Incidence (%) Adjusted Odds Ratio for Mortality= 2.21, 95% CI 1.97-2.47, p<0.001 11

  12. In-Hospital Clinical OutcomesSTEMI versus NSTEMI P<0.0001 for each outcome Incidence (%) STEMI NSTEMI STEMI NSTEMI STEMI NSTEMI STEMI NSTEMI 12

  13. In-Hospital Outcomes in Patients with Normal Pre-Procedural TIMI Flow 13

  14. Limitations • No reflow based on standardized NCDR definition with determination by individual sites, thus true incidence may be under-reported • Detailed angiographic variables (TIMI perfusion grade) may have greater prognostic value but are not available • Rates of cardiac biomarker measurement variable between sites, thus rates of periprocedural MI may be underreported • Rates of preprocedural vs. bailout GP IIb-IIIa antagonist that may attenuate no reflow not available 14

  15. Conclusions • In this largest cohort analysis of patients who developed no reflow after PCI for AMI, no reflow phenomenon is relatively uncommon • No reflow portends worse angiographic and clinical outcomes, including doubling of adjusted risk of in-hospital mortality 15

  16. Conclusions • No reflow patients had longer symptom onset to admission before PCI and greater odds of presentation with STEMI, which implicates greater thrombus burden that perpetuates no reflow • Association of impaired preprocedural epicardial flow with no reflow is likely representation of thrombus causing occlusion of epicardial coronary artery that propagates development of no reflow 16

  17. Conclusions • Exclusion of patients with impaired preprocedural epicardial blood flow that are likely to have greater thrombus burden attenuates incidence of no reflow underscoring importance of angiographic thrombus burden in perpetuation of epicardial no reflow • Strategies to prevent development of no reflow and mitigate its consequences are warranted 17

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