Title : Epinephrine for managing no-reflow phenomenon: A systematic review
Abstract:
Currently, no pharmacological or device-based intervention has been fully validated to reverse the no-reflow phenomenon. Several agents can be used in the case of primary or refractory no-reflow phenomenon, but none of them have a promising effect. We conducted a systematic review of the literature to evaluate the efficacy and safety of Intracoronary (IC) Epinephrine in the management of no-reflow phenomenon following Percutaneous Coronary Intervention (PCI).
We searched PubMed and Scopus databases up to 28th May 2022, with additional manually searching Google Scholar and reviewing the reference lists of the relevant studies. Cohort studies, case series, and interventional studies written in English which assessed the efficacy and/or safety of IC Epinephrine in patients with no-flow phenomenon were included in our review.
Six of the 646 articles identified in the initial search met our inclusion criteria. IC Epinephrine was used either as a first-line treatment of the no-reflow phenomenon (two randomized clinical trials (RCTs) or after the failure of conventional agents such as adenosine, calcium channel blockers, and nitrates (two cohort studies and two case series) for restoring the coronary flow, mainly after primary PCI. As first-line therapy, IC Epinephrine reinstated coronary flow in over 90% of patients in both RCTs, which significantly outperformed IC Adenosine (78%) but lagged behind the combination of Verapamil and Tirofiban (100%) in this regard. In the refractory no-flow phenomenon, successful reperfusion (TIMI flow grade = 3) was achieved in 3 out of four patients after the administration of IC Epinephrine based on the results from both case series. Their findings were confirmed by a recent cohort study that further compared IC Epinephrine with IC Adenosine and found significant differences between them in terms of efficacy (% TIMI flow grade 3: [ 69.1% vs. 52.7%, respectively] and one-year major adverse cardiac events (MACE) outcomes [11.3% vs. 26.7, respectively]). Overall, malignant ventricular arrhythmias were not reported in the patients who were treated with IC Epinephrine.
Results from available evidence suggest that intracoronary Epinephrine might be an effective and safe agent in managing the no-reflow phenomenon. Despite other agents, using epinephrine is not limited by hypotension and cardiogenic shock. Further randomized clinical trial studies are recommended to confirm its usage in the no-reflow phenomenon.
