title: Intracoronary epinephrine in the treatment of refractory no-reflow after primary percutaneous coronary intervention: a retrospective study.
abstract: BACKGROUND
  Despite the advances in medical and interventional treatment modalities, some patients develop epicardial coronary artery reperfusion but not myocardial reperfusion after primary percutaneous coronary intervention (PCI), known as no-reflow. The goal of this study was to evaluate the safety and efficacy of intracoronary epinephrine in reversing refractory no-reflow during primary PCI.
  
  
  METHODS
  A total of 248 consecutive STEMI patients who had undergone primary PCI were retrospectively evaluated. Among those, 12 patients which received intracoronary epinephrine to treat a refractory no-reflow phenomenon were evaluated. Refractory no-reflow was defined as persistent TIMI flow grade (TFG) ≤ 2 despite intracoronary administration of at least one other pharmacologic intervention. TFG, TIMI frame count (TFC), and TIMI myocardial perfusion grade (TMPG) were recorded before and after intracoronary epinephrine administration.
  
  
  RESULTS
  A mean of 333 ± 123 mcg of intracoronary epinephrine was administered. No-reflow was successfully reversed with complete restoration of TIMI 3 flow in 9 of 12 patients (75%). TFG improved from 1.33 ± 0.49 prior to epinephrine to 2.66 ± 0.65 after the treatment (p < 0.001). There was an improvement in coronary flow of at least one TFG in 11 (93%) patients, two TFG in 5 (42%) cases. TFC decreased from 56 ± 10 at the time of no-reflow to 19 ± 11 (p < 0.001). A reduction of TMPG from 0.83 ± 0.71 to 2.58 ± 0.66 was detected after epinephrine bolus (p < 0.001). Epinephrine administration was well tolerated without serious adverse hemodynamic or chronotropic effects. Intracoronary epinephrine resulted in significant but tolerable increase in heart rate (68 ± 13 to 95 ± 16 beats/min; p < 0.001) and systolic blood pressure (94 ± 18 to 140 ± 20; p < 0.001). Hypotension associated with no-reflow developed in 5 (42%) patients. During the procedure, intra-aortic balloon pump counterpulsation was required in two (17%) patients, transvenous pacing in 2 (17%) cases, and both intra-aortic balloon counterpulsation and transvenous pacing in one (8%) patients. One patient (8%) died despite all therapeutic measures.
  
  
  CONCLUSIONS
  Intracoronary epinephrine may become an effective alternative in patients suffering refractory no-reflow following primary PCI.
authors.affiliation: Department of Cardiology, Derince Education and Research Hospital, Derince, Turkey. aksutolga@gmail.com.
authors.forename: Tolga
authors.initials: T
authors.lastname: Aksu
authors.affiliation: Department of Cardiology, Derince Education and Research Hospital, Derince, Turkey. mettalamus@gmail.com.
authors.forename: Tumer Erdem
authors.initials: TE
authors.lastname: Guler
authors.affiliation: Department of Cardiology, Ankara Yuksek Ihtisas Hospital, Ankara, Turkey. aysecolak1@windowslive.com.
authors.forename: Ayse
authors.initials: A
authors.lastname: Colak
authors.affiliation: Department of Cardiology, Diyarbakir Education and Research Hospital, Diyarbakir, Turkey. dr.erkan.baysal@hotmail.com.
authors.forename: Erkan
authors.initials: E
authors.lastname: Baysal
authors.affiliation: Department of Cardiology, Mersin State Hospital, Mersin, Turkey. mndrks@gmail.com.
authors.forename: Mine
authors.initials: M
authors.lastname: Durukan
authors.affiliation: Department of Cardiology, Kutahya Evliya Celebi Education and Research Hospital, Kutahya, Turkey. medicineman_tr@hotmail.com.
authors.forename: Taner
authors.initials: T
authors.lastname: Sen
authors.affiliation: Department of Cardiology, Ankara Numune Education and Research Hospital, Ankara, Turkey. umit.guray@gmail.com.
authors.forename: Umit
authors.initials: U
authors.lastname: Guray
mesh_terms: D000318:Adrenergic beta-Agonists / Q000008:administration & dosage* / Q000009:adverse effects; D001794:Blood Pressure / Q000187:drug effects; D017023:Coronary Angiography; D004837:Epinephrine / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000601:surgery; D054318:No-Reflow Phenomenon / Q000000981:diagnostic imaging / Q000188:drug therapy*; D062645:Percutaneous Coronary Intervention; D012189:Retrospective Studies; D014463:Ultrasonography
chemical_list: D000318:Adrenergic beta-Agonists; D004837:Epinephrine