The association between admission hyperglycaemia and the no-reflow phenomenon in STEMI patients undergoing primary percutaneous coronary intervention

Amr Elkammash; Mohamed Sobhy; Amr Zaki; Sherif Ayad

doi:10.7861/fhj.9-2-s23

Introduction

No-reflow phenomenon is not uncommon in acute myocardial infarction patients treated by primary percutaneous coronary intervention (PPCI). It is associated with poorer left ventricular systolic dysfunction and higher mortality in such patients.¹ Diabetes was linked to increased incidence of no-reflow in PPCI.² We hypothesised that acute admission hyperglycemia, rather than diabetes, is responsible for this complication.

Materials and methods

We prospectively studied 120 consecutive ST-elevation myocardial infarction (STEMI) patients presenting to two PPCI centres over a period of 6 months. We included all the patients eligible for PPCI according to the European Society of Cardiology (ESC) guidelines.³ We excluded patients with previous PCI and stent thrombosis and patients with previous coronary artery bypass grafting (CABG). The local research ethics committee has approved the study protocol and we followed the Helsinki declaration of research ethics in human beings including informed consents. The patients were divided into two groups based on the coronary flow post-PPCI (normal flow and no-reflow). No reflow is defined as the absence of coronary TIMI 3 flow post PCI without mechanical obstruction.¹ A professional statistician did the analysis using IBM SPSS 21.0 software.

Results and discussion

The incidence of no-reflow was 17.5% (n=21). There was no significant difference between the two groups regarding the clinical characteristics and the different cardiovascular risk factors including diabetes (Table 1). The median of admission random plasma glucose (RPG) level was significantly higher in the no-reflow group (15.5 vs 8.3 mmol/L; p=0.001; Fig 1). A possible explanation is that hyperglycemia increases leucocytes’ adhesion molecules, causing microvascular obstruction and Elastase-induced endothelial damage.⁴ This augments thrombus formation and impairs ischaemic preconditioning.⁵ The study was limited by the small study population size and the narrow geographical area of recruitment.

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Table 1.

The clinical characteristics of the studied groups

Fig 1.

The admission random plasma glucose level in the studied groups.

Conclusion

Admission hyperglycemia, rather than diabetes, is associated with a higher incidence of no-reflow post-PPCI. The control of admission hyperglycaemia can help to reduce the peri-procedural complications of PPCI.

References

↵
1. Niccoli G
, Burzotta F, Galiuto L, et al. Myocardial no-reflow in humans. J Am Coll Cardiol 2009;54:281–92.
OpenUrl FREE Full Text
↵
1. Pantea-Roșan LR
, Ţica OA, Moisi M, et al. Predictors of no-reflow phenomenon: diabetes mellitus type II and obesity and their associated mortality in stemi patients after primary PCI. Intern Med 2019;16:7–12.
OpenUrl
↵
1. Ibanez B
, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119–77.
OpenUrl CrossRef PubMed
↵
1. Hokama JY
, Ritter LS, Davis-Gorman G, et al. Diabetes enhances leukocyte accumulation in the coronary microcirculation early in reperfusion following ischemia. J Diabetes Complications 2000;14:96–107.
OpenUrl CrossRef PubMed
↵
1. Ito H
, Iwakura K, Kawano S, et al. Predictive factors for development of the no-reflow phenomenon in patients with reperfused anterior wall acute myocardial infarction. J Am Coll Cardiol 2001;38:472–7.
OpenUrl FREE Full Text