Intracoronary vasoactive therapy for no-reflow during primary PCI

The no-reflow phenomenon frequently complicates primary percutaneous coronary intervention (PCI) and is linked to adverse outcomes. However, evidence supporting a specific pharmacological treatment is still limited.

We performed a systematic review and frequentist network meta-analysis of randomized controlled trials comparing intracoronary adenosine, epinephrine, nitroprusside, and verapamil administered during primary PCI for the treatment of the no-reflow phenomenon. The primary efficacy endpoint was restoration of Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow at the end of the procedure. Secondary endpoints included ST-segment resolution (STR), major adverse cardiovascular events (MACE), and all-cause mortality. Bayesian analysis, quality-based sensitivity analyses, and meta-regression to assess potential confounders were also conducted.

A total of 1,674 patients were included in the analysis. Both epinephrine (OR 2.81; 95% CI, 1.72–4.58) and verapamil (OR 2.84; 95% CI, 1.63–4.95) were associated with significantly higher odds of achieving final TIMI 3 flow compared with control, findings consistent with the Bayesian analysis. In sensitivity analyses, adenosine was also associated with improved TIMI 3 flow (OR 1.53; 95% CI, 1.12–2.10). Meta-regression found no confounding effect from intraprocedural glycoprotein IIb/IIIa inhibitors or mechanical thrombectomy. For STR, significant benefits were observed with epinephrine (OR 4.30; 95% CI, 2.19–8.45), verapamil (OR 2.85; 95% CI, 1.64–4.96), and adenosine (OR 1.38; 95% CI, 1.04–1.84), compared with control. None of the therapies significantly reduced MACE or mortality, although the analysis was underpowered for these outcomes.

Intracoronary verapamil and epinephrine are associated with consistent improvements in final TIMI 3 flow compared with control.For image description, please refer to the figure legend and surrounding text.  For image description, please refer to the figure legend and surrounding text.