Risk assessment score of no-reflow phenomenon in predicting myocardial perfusion disorders by contrast echocardiography in ST-segment elevation myocardial infarction patients after endovascular revascularization

Aim. To study the capabilities of risk assessment score for angiographic no-reflow phenomenon in predicting myocardial perfusion disorders according to contrast echocardiography data in ST-segment elevation myocardial infarction (STEMI) patients after percutaneous coronary interventions (PCI).

Material and Methods. A total of 40 STEMI patients after PCI were included in the analysis. The individual risk score for noreflow phenomenon was calculated using previously developed scale in all patients. Risk of no-reflow was assessed as high when the score was ≥ 35. All patients underwent contrast echocardiography with myocardial perfusion assessment within six hours after PCI. The clinical angiographic characteristics and in-hospital outcomes were analyzed including the lethality, myocardial infarction recurrence, and stent thrombosis rates.

Results. High risk of no-reflow phenomenon was identified in 13 (32.5%) patients. The rates of angiographic no-reflow phenomenon (46.2% versus 11.1%, p = 0.038) as well as contrast-enhanced echocardiography-based myocardial perfusion disorders (61.5% versus 18.5%, p = 0.011) were significantly higher in the high-risk patient group. According to results of ROCanalysis, no-reflow risk assessment scale for identifying patients with myocardial perfusion disorders according to contrast echocardiography had sensitivity/specificity/area under the curve (AUC) of 62%/85%/0.789 (p = 0.003).

Conclusions. Angiographic no-reflow risk assessment score allowed to identify patients with high risk of developing myocardial perfusion disorders according to contrast echocardiography.

1. Neumann F.J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J. 2019;40(2):87–165. DOI: 10.1093/eurheartj/ehy394.

2. Szummer K., Wallentin L., Lindhagen L., Alfredsson J., Erlinge D., Held C. et al. Improved outcomes in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence- based treatments: Experiences from the SWEDEHEART registry 1995–2014. Eur. Heart J. 2017;38(41):3056–3065. DOI: 10.1093/eurheartj/ehx515.

3. Kloner R.A., King K.S., Harrington M. No-reflow phenomenon in heart and brain. Am. J. Physiol. Heart Circ. Physiol. 2018;315(3):550–562. DOI: 10.1152/ajpheart.00183.2018.

4. Bessonov I.S., Kuznetsov V.A., Gorbatenko E.A., Sapozhnikov S.S., Dyakova A.O., Zyrianov I.P. et al. Development of a risk score for no-reflow phenomenon after percutaneous coronary interventions in patients with ST-segment elevation myocardial infarction. Circulatory Pathology and Cardiac Surgery. 2020;24(3):68. (In Russ.). DOI: 10.21688/1681-3472-2020-3S-68-76.

5. Bessonov I.S., Dyachkov S.M. Risk calculator for the “no-reflow” phenomenon. Certificate of registration of a computer program 2020661255, 21.09.2020. (In Russ.).

6. Senior R., Becher H., Monaghan M., Agati L., Zamorano J., Vanoverschelde J.L. et al. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017. Eur. Heart J. Cardiovasc. Imaging. 2017;18(11):1205–1205af. DOI: 10.1093/ehjci/jex182.

7. Antman E.M., Cohen M., Bernink P.J., McCabe C.H., Horacek T., Papuchis G. et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000;284(7):835–842. DOI: 10.1001/jama.284.7.835.

8. Van ‘t Hof A.W., Liem A., Suryapranata H., Hoorntje J.C., de Boer M.J., Zijlstra F. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: myocardial blush grade. Zwolle Myocardial Infarction Study Group. Circulation. 1998;97(23):2302–2306. DOI: 10.1161/01.cir.97.23.2302.

9. Gibson C.M., de Lemos J.A., Murphy S.A., Marble S.J., McCabe C.H., Cannon C.P. et al. Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction: A TIMI 14 substudy. Circulation. 2001;103(21):2550–2554. DOI: 10.1161/01.cir.103.21.2550.

10. Kamarudin A.N., Cox T., Kolamunnage-Dona R. Time-dependent ROC curve analysis in medical research: Current methods and applications. BMC Med. Res. Methodol. 2017;17(1):53. DOI: 10.1186/s12874-017-0332-6.

11. Durante A., Laricchia A., Benedetti G., Esposito A., Margonato A., Rimoldi O. et al. Identification of high-risk patients after st-segment-elevation myocardial infarction: comparison between angiographic and magnetic resonance parameters. Circ. Cardiovasc. Imaging. 2017;10(6):e005841. DOI: 10.1161/CIRCIMAGING.116.005841.

12. Krinochkin D.V., Bessonov I.S., Kuznetsov V.A., Yaroslavskaya E.I., Takkand A.G. Contrast echocardiography with assessment of myocardial perfusion in diagnostics of no-reflow phenomenon in a patient with acute myocardial infarction. Atheroskleroz. 2019;15(2):52–58. (In Russ.). DOI: 10.15372/ATER20190208.

13. Lindner J.R. Microvascular impairment after myocardial infarction: It is not just about obstruction. Circ. Cardiovasc. Imaging. 2020;13(6):e011083. DOI: 10.1161/CIRCIMAGING.120.011083.

14. Kloner R.A. The importance of no-reflow/microvascular obstruction in the STEMI patient. Eur. Heart J. 2017;38(47):3511–3513. DOI: 10.1093/eurheartj/ehx288.

15. De Waha S., Patel M.R., Granger C.B., Ohman E.M., Maehara A., Eitel I. et al. Relationship between microvascular obstruction and adverse events following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: an individual patient data pooled analysis from seven randomized trials. Eur. Heart J. 2017;38(47):3502–3510. DOI: 10.1093/eurheartj/ehx414.

16. Xie F., Qian L., Goldsweig A., Xu D., Porter T.R. Event-free survival following successful percutaneous intervention in acute myocardial infarction depends on microvascular perfusion. Circulation: Cardiovascular Imaging. 2020;13(6):e010091. DOI: 10.1161/CIRCIMAGING.119.010091.

17. Niccoli G., Kharbanda R.K., Crea F., Banning A.P. No-reflow: Again prevention is better than treatment. Eur. Heart J. 2010;31(20):2449–2455. DOI: 10.1093/eurheartj/ehq299.