title: The REFLO-STEMI trial comparing intracoronary adenosine, sodium nitroprusside and standard therapy for the attenuation of infarct size and microvascular obstruction during primary percutaneous coronary intervention: study protocol for a randomised controlled trial.
abstract: BACKGROUND
  Microvascular obstruction (MVO) secondary to ischaemic-reperfusion injury is an important but underappreciated determinant of short- and longer-term outcome following percutaneous coronary intervention (PCI) treatment of ST-elevation myocardial infarction (STEMI). Several small studies have demonstrated a reduction in the degree of MVO utilising a variety of vasoactive agents, with adenosine and sodium nitroprusside (SNP) being most evaluated. However, the evidence base remains weak as the trials have had variable endpoints, differing drug doses and delivery. As such, the results regarding benefit are conflicting.
  
  
  METHODS
  The REperfusion Facilitated by LOcal adjunctive therapy in STEMI (REFLO-STEMI) trial is a multicentre, prospective, randomised, controlled, open label, study with blinded endpoint analysis: Patients presenting within 6 h of onset of STEMI and undergoing planned primary PCI (P-PCI) with TIMI 0/1 flow in the infarct-related artery (IRA) and no significant bystander coronary artery disease on angiography, are randomised into one of three groups: PCI with adjunctive pharmacotherapy (intracoronary adenosine or SNP) or control (standard PCI). All receive Bivalirudin anticoagulation and thrombus aspiration. The primary outcome is infarct size (IS) (determined as a percentage of total left ventricular mass) measured by cardiac magnetic resonance imaging (CMRI) undertaken at 48 to 72 h post P-PCI. Secondary outcome measures include MVO (hypoenhancement within infarct core) on CMRI, angiographic markers of microvascular perfusion and MACE during 1-month follow-up. The study aims to recruit 240 patients (powered at 80% to detect a 5% absolute reduction in IS).
  
  
  CONCLUSIONS
  The REFLO-STEMI study has been designed to address the weaknesses of previous trials, which have collectively failed to demonstrate whether adjunctive pharmacotherapy with adenosine and/or SNP can reduce measures of myocardial injury (infarct size and MVO) and improve clinical outcome, despite good basic evidence that they have the potential to attenuate this process. The REFLO-STEMI study will be the most scientifically robust trial to date evaluating whether adjunctive therapy (intracoronary adenosine or SNP following thrombus aspiration) reduces CMRI measured IS and MVO in patients undergoing P-PCI within 6 h of onset of STEMI.
  
  
  BACKGROUND
  Trial registered 20th November 2012: ClinicalTrials.gov Identifier NCT01747174.
authors.forename: Sheraz A
authors.initials: SA
authors.lastname: Nazir
authors.forename: Jamal N
authors.initials: JN
authors.lastname: Khan
authors.forename: Islam Z
authors.initials: IZ
authors.lastname: Mahmoud
authors.forename: John P
authors.initials: JP
authors.lastname: Greenwood
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Blackman
authors.forename: Vijay
authors.initials: V
authors.lastname: Kunadian
authors.forename: Martin
authors.initials: M
authors.lastname: Been
authors.forename: Keith R
authors.initials: KR
authors.lastname: Abrams
authors.forename: Robert
authors.initials: R
authors.lastname: Wilcox
authors.forename: A A Jennifer
authors.initials: AA
authors.lastname: Adgey
authors.forename: Gerry P
authors.initials: GP
authors.lastname: McCann
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, LE3 9QP Leicester, UK. agershlick@aol.com.
authors.forename: Anthony H
authors.initials: AH
authors.lastname: Gershlick
mesh_terms: D000241:Adenosine / Q000008:administration & dosage* / Q000009:adverse effects; D002985:Clinical Protocols; D017023:Coronary Angiography; D003326:Coronary Circulation / Q000187:drug effects*; D003331:Coronary Vessels / Q000187:drug effects* / Q000503:physiopathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008833:Microcirculation / Q000187:drug effects*; D009203:Myocardial Infarction / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D055414:Myocardial Perfusion Imaging; D009599:Nitroprusside / Q000008:administration & dosage* / Q000009:adverse effects; D054318:No-Reflow Phenomenon / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects; D011446:Prospective Studies; D015427:Reperfusion Injury / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D012107:Research Design; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom; D014665:Vasodilator Agents / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D014665:Vasodilator Agents; D009599:Nitroprusside; D000241:Adenosine