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No-reflow phenomenon and prognosis in patients with acute myocardial infarction

Nature Clinical Practice Cardiovascular Medicine volume 3, pages 499–506 (2006)Cite this article

Abstract

The rapid restoration of coronary flow to the jeopardized myocardium has become an essential part of therapy after acute myocardial infarction. Despite an open infarct-related artery, breakdown of or obstruction to coronary microvasculature can markedly reduce blood flow to the infarct zone. This effect is known as the no-reflow phenomenon. Advances in imaging modalities have improved visualization of no reflow, showing its frequency to be higher than was estimated by clinical judgment alone. This phenomenon is important because it correlates with infarct size and provides useful prognostic information. No reflow is associated with reduced left ventricular ejection fraction, left ventricular remodeling, and poor clinical outcomes, placing patients with this effect in a high-risk group among reperfused patients. The focus of reperfusion therapy is shifting towards improved myocardial perfusion, which could promote functional recovery of viable muscle, reduce infarct expansion, and increase the delivery of blood-borne components, thereby accelerating the healing process. Various pharmacologic interventions and catheter-based devices to retrieve embolic materials have been proposed. Further studies to improve understanding of the pathophysiology of microvascular dysfunction will, however, help in the further development of preventive and therapeutic strategies. In this article, I discuss in depth the data available on the no-reflow phenomenon.

Key Points

  • Successful restoration of epicardial coronary artery patency with reperfusion therapy after acute myocardial infarction does not necessarily translate into improved tissue perfusion, resulting in the no-reflow phenomenon

  • As well as correlating closely with myocardial infarction size, the no-reflow phenomenon can provide valuable prognostic indications

  • At least two mechanisms lead to microvascular obstruction: capillary occlusion and microemboli to coronary resistance vessels

  • Contrast perfusion defects on myocardial contrast echocardiography, indicating no reflow, are often associated with sluggish coronary flow and sustained ST-segment elevation

  • Reduction of embolic particle concentration with antiplatelet therapy and removal of thrombus and plaque burden with catheter-based interventions can improve coronary blood flow

  • Several pharmacologic interventions have been tested to reduce the no-reflow phenomenon and some of them are available for clinical use

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Figure 1: Myocardial contrast echocardiograms in a patient with reperfused anterior myocardial infarction.

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Acknowledgements

I thank Dr S Kaul, Oregon Health & Science University, Portland, OR, USA, for valuable discussion and suggestions.

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Authors and Affiliations

  1. Chief Director of the Division of Cardiology, Sakurabashi Watanabe Hospital, Osaka, Japan

    Hiroshi Ito

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  1. Hiroshi Ito
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Ito, H. No-reflow phenomenon and prognosis in patients with acute myocardial infarction. Nat Rev Cardiol 3, 499–506 (2006). https://doi.org/10.1038/ncpcardio0632

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