Kidney Dysfunction and the Risk of Slow-Flow / No-Reflow During Primary PCI for Acute Myocardial Infarction
DOI:
https://doi.org/10.55958/jcvd.v21i3.282Abstract
Background:Primary percutaneous coronary intervention (pPCI) is considered the gold standard treatment for patients with acute ST-elevation myocardial infarction (STEMI), as it significantly lowers both short and long-term mortality. This procedure successfully restores normal blood flow (TIMI-3 flow) in the infarct-related artery (IRA). Compromised kidney function is a recognized predictor of increased mortality and complications in STEMI patients undergoing primary PCI (pPCI). This adverse prognostic effect can appear even with a mild reduction in renal function. Several studies have also identified impaired kidney function as an independent risk factor for the development of the slow-flow or no-reflow (SF/NR) phenomenon.
Objective: To see the association of kidney dysfunction with patients having slow-flow/no- reflow phenomenon in STEMI patients undergoing pPCI and to evaluate its prognostic effect on short-term mortality in our local population
Material and Methods: The prospective observational study was conducted from 20-01-2025 to 15-05-2025 at the Cardiology Department, PIC Lahore. Patients of both genders age ranging from 18-75 years were enrolled to investigate the association between estimated glomerular filtration rate (eGFR) or serum creatinine and the incidence of SF/NR who were undergoing pPCI.
Results: Total enrollment of 227 patients having mean age 56.1 years, 154(68.0%) males and 73(32.0%) females, in which 16(7.0%) developed slow-flow/no-reflow post-PCI. Duration of pain, A.Fib, complete heart block, and heart failure have statistically significant differences as p- value < 0.05 and poorer baseline renal function, as evidenced by a lower eGFR (76.5±5.4 vs. 89.6±1.0 mL/min/1.73m², p=0.001). Angiographically, the no-reflow group had higher rates of pre- procedural total occlusion (TIMI 0 flow) and lower stent implantation rates. Mortality 1(6.3%) observed in slow / no-flow group with an insignificant p-value 0.141. Increasing age is an independent predictor, with each additional year raising the odds of slow/no-flow by about 4%. Hypertension doubled the likelihood of developing no-reflow p-value 0.020.
Conclusion: Impaired renal function significantly predicts slow-flow/no-reflow following primary PCI, underscoring the need for renal-based risk stratification before intervention
References
Kai T, Oka S, Hoshino K, Watanabe K, Nakamura J, Abe M, Watanabe A. Renal dysfunction as a predictor of slow-flow/no-reflow phenomenon and impaired ST segment resolution after percutaneous coronary intervention in ST-elevation myocardial infarction with initial thrombolysis in myocardial infarction grade 0. Circulation Journal. 2021 Sep 24;85(10):1770-8.
Refaat H, Tantawy A, Gamal AS, Radwan H. Novel predictors and adverse long-term outcomes of No-reflow phenomenon in patients with acute ST elevation myocardial infarction undergoing primary percutaneous coronary intervention. Indianheartjournal. 2021 Jan 1;73(1):35-43..
Khalfallah M, Allaithy A, MariaDA. Impactof thetotalischemiatimeon no-reflow phenomenoninpatientswithSTelevationmyocardialinfarctionundergoingprimary percutaneous coronary intervention. Anatolian journal of cardiology. 2022 May 1;26(5):382.
Ashoori A, Pourhosseini H, Ghodsi S, Salarifar M, Nematipour E, Alidoosti M, Haji- ZeinaliAM,NozariY,AmirzadeganA,AghajaniH,JalaliA. CHA2DS2-VASc score as an independent predictor of suboptimal reperfusion and short-term mortality after primary PCI in patients with acute ST segment elevation myocardial infarction. Medicina. 2019 Feb 1;55(2):35.
Mirbolouk F, Gholipour M, Salari A, Shakiba M, Kheyrkhah J, Nikseresht V, Sotoudeh N,MoghadamN,MirboloukMJ.CHA2DS2-VAScscorepredictno-reflowphenomenon in primary percutaneous coronary intervention in primary percutaneous coronary intervention. Journal of cardiovascular and thoracic research. 2018 Mar 18;10(1):46.
Ashraf T, Khan MN, Afaque SM, Aamir KF, Kumar M, Saghir T, Rasool SI, Rizvi SN, SialJA,NadeemA,KhanAA.Clinicalandproceduralpredictorsandshort-termsurvival of the patients with no reflow phenomenon after primary percutaneous coronary intervention. International journal of cardiology. 2019 Nov 1;294:27-31.
Sabin P, Koshy AG, Gupta PN, Sanjai PV, Sivaprasad K, Velappan P, Velayudhan RV. Predictorsofno-reflowduringprimaryangioplastyforacutemyocardialinfarction, from Medical College Hospital, Trivandrum. Indian heart journal. 2017 Apr 1;69:S34-45.
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, ExecutiveGrouponbehalfoftheJointEuropeanSocietyofCardiology(ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). Journal of the American college of cardiology. 2018 Oct 30;72(18):2231-64.
Khalfallah M, Allaithy A, MariaDA. Impact of the total ischemia time on no-reflow phenomenoninpatientswithSTelevationmyocardialinfarctionundergoingprimary percutaneous coronary intervention. Anatolian journal of cardiology. 2022 May 1;26(5):382..
Fajar JK, Heriansyah T, Rohman MS. The predictors of no reflow phenomenon after percutaneouscoronaryinterventioninpatientswithSTelevationmyocardialinfarction:a meta-analysis. Indian Heart J 2018;70(suppl 3):S406–S418.
Kumar R, Ammar A, Saghir T, Sial JA, Khan KA, Shah JA, Shaikh AH, Rizvi SN, Qamar N, Karim M. Development and validation of a novel risk stratification model for slow-flow/no-reflowduringprimarypercutaneouscoronaryintervention(theRK-SF/NR score). The American Journal of Cardiology. 2022 May 15;171:32-9.
Panchal H. B., Zheng S., Devani K., et al. Impact of chronic kidney disease on revascularizationandoutcomesinpatientswithST-elevationmyocardialinfarction.The American Journal of Cardiology . 202;150:15–23. doi: 10.1016/j.amjcard.2021.03.057.
Hashimoto Y., Ozaki Y., Kan S., et al. Impact of chronic kidney disease on in-hospital and 3-year clinical outcomes in patients with acute myocardial infarction treated by contemporarypercutaneouscoronaryinterventionandoptimalmedicaltherapy-insights from the J-MINUET study. Circulation Journal . 2021;85(10):1710–1718. doi: 10.1253/circj.cj-20-1115
.KaiT.,OkaS.,HoshinoK.,etal. Renaldysfunction as apredictorofslow-flow/No- reflowphenomenonandimpairedSTsegmentresolutionafterpercutaneouscoronary intervention in ST-elevation myocardial infarction with initial thrombolysis in myocardial infarction grade 0. Circulation Journal . 2021;85(10):1770–1778. doi: 10.1253/circj.cj-21-0221
Sabin P, Koshy AG, Gupta PN, Sanjai PV, Sivaprasad K, Velappan P, Velayudhan RV. Predictorsofno-reflowduringprimaryangioplastyforacutemyocardialinfarction,from Medical College Hospital, Trivandrum. Indian heart journal. 2017 Apr 1;69:S34-45.
SavicL,MrdovicI,AsaninM,StankovicS,Lasica R,Krljanac G,RajicD,SimicD.The Impact of Kidney Function on the Slow?Flow/No?Reflow Phenomenon in Patients Treated with Primary Percutaneous Coronary Intervention: Registry Analysis. Journal of Interventional Cardiology. 2022;2022(1):5815274.
HouseAA,etal.HeartandKidneyInteractionsin theSettingofAcuteCoronary Syndromes. J Am Heart Assoc. 2021;10(12):e020569.
CharytanDM.IstheFailingKidneyattheHeartofPoorCoronaryFlow?. Circulation. 2021;143(12):1195-1197.
Jung C, et al. Impact of the haemoglobin level on microvascular obstruction in ST- elevationmyocardialinfarction. EurHeartJAcuteCardiovascCare.2021;10(2):139- 146.
NdrepepaG,KastratiA.TheNo-ReflowPhenomenon:AUpdateonDiagnosisand Management. Front Cardiovasc Med. 2022;9:857918.
Panchal HB, Zheng S, Devani K, White CJ, Leinaar EF, Mukherjee D, Mamas M, Banerjee S, Bhatt DL, Jneid H, Samady H. Impact of chronic kidney disease on revascularizationandoutcomesinpatientswithST-elevationmyocardialinfarction.The American journal of cardiology. 2021 Jul 1;150:15-23.
