Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC ZQP73b5JnwLLWRGqqYmjvVR 00473 S0066-782X2021000400473 abc.20210114 10.36660/abc.20210114 Minieditorial Escores Angiográficos na Predição de No-Reflow, a Injuria Miocárdica pode não se Encerrar com a Reperfusão Tamazato Adriano Ossuna 1 2 0000-0001-6166-9777 Tamazato Thais Chang Valente 1 2 0000-0002-4762-0579 Bezerra Cristiano Guedes 1 2 3 Hospitais Aliança, São Rafael Cardiopulmonar – Rede D’Or Salvador BA Brasil Hospitais Aliança, São Rafael, Cardiopulmonar – Rede D’Or, Salvador, BA - Brasil. Hospital Ana Nery Salvador BA Brasil Hospital Ana Nery, Salvador, BA - Brasil. Universidade Federal da Bahia Hospital Universitário Professor Edgard Santos Salvador BA Brasil Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA - Brasil. Correspondência: Cristiano Guedes Bezerra • Universidade Federal da Bahia - Hemodinâmica e Cardiologia Intervencionista R. Dr. Augusto Viana, s/n. CEP 40110-060, Canela, Salvador, BA – Brasil. E-mail: cristianoguedes@live.com 23 04 2021 03 2021 116 3 473 474 This is an open-access article distributed under the terms of the Creative Commons Attribution License Palavras-chave Intervenção Coronária Percutânea/métodos Infarto do Miocárdio Aterosclerose Trombose Placa Aterosclerótica Embolização Terapêutica

O infarto com supradesnivelamento de segmento ST (IAMCSST) geralmente é precipitado pela ruptura ou erosão de uma placa aterosclerótica e consequente formação de trombo oclusivo. A intervenção coronária percutânea precoce é o tratamento de escolha por propiciar uma revascularização mais completa e menores complicações do tipo sangramento quando comparado à fibrinólise.1,2

Nas últimas décadas observamos uma evolução substancial no tratamento farmacológico e invasivo do IAMCSST, o que reduziu significativamente a mortalidade precoce. Diversas variáveis influenciam os desfechos clínicos, entre elas, idade do paciente, tempo para reperfusão, complexidade angiográfica e a ocorrência ou não do fenômeno de no-reflow (NR) durante o tratamento percutâneo.3,4

NR é definido por inadequada perfusão miocárdica em determinado território, na ausência de obstrução mecânica da coronária epicárdica5 e está associado a pior prognóstico clínico.6,7

Nessa edição dos Arquivos Brasileiros de Cardiologia o artigo “O Escore Gensini e a carga trombótica adicionam valor preditivo ao escore SYNTAX na detecção de no-reflow após o infarto do miocárdio”, no qual os autores avaliaram a angiografia de 481 pacientes admitidos por IAMCSST e calcularam os escores SYNTAX, Gensini modificado, além da avaliação da carga trombótica de forma objetiva. Foi encontrada uma melhor acurácia da predição do fenômeno NR quando utilizada a combinação das três avaliações.8

O escore de Gensini foi descrito pela primeira vez em 1975, leva em consideração três parâmetros para cada lesão coronária: gravidade da obstrução, multiplicada por um fator de acordo com importância da região irrigada pela artéria e ajustada pela presença de colaterais;9 contempla estenoses menores que 25% e é, portanto, mais sensível a obstruções parciais que o SYNTAX SCORE. A quantificação objetiva da carga trombótica é determinada pela escala TIMI de 0 a 5, no qual 0 é a ausência de trombo e 5 é a presença de trombo oclusivo.10

Relacionar esses escores angiográficos com a presença de fenômeno de NR faz sentido fisiopatológico, pois apesar de não ser totalmente esclarecido, o fenômeno de NR em pacientes submetidos à intervenção percutânea primária tem como uma das causas a microembolização distal,11 que por sua vez depende das variáveis angiográficas estudadas pelos autores. No estudo publicado não foram reportados dados sobre os procedimentos (tromboaspiração, stents, pós-dilatação), medicações adjuvantes e reversibilidade do fenômeno que também impactam significativamente no prognóstico angiográfico e clínico.

Predizer um fenômeno potencialmente catastrófico ganha importância quando impacta em modificação de conduta antes deste ocorrer. O estudo DEFER-STEMI, publicado em 2014, tocou justamente neste ponto: um trial prova de conceito que avaliou o impacto de atrasar o implante de stent (com a artéria já reperfundida por balão ou tromboaspiração) com objetivo de reduzir a incidência de NR e o tamanho do infarto, avaliado pela ressonância magnética - o racional é que adiar o implante do stent pode dar tempo para ação das drogas antitrombóticas, redução da carga de trombo e consequentemente menos NR e menor área infartada. De fato, nesse estudo, houve uma redução significativa de NR (de 14% para 2% no grupo stent-adiado) e melhora do índice de recuperação miocárdica em seis meses.12 Mais tarde, em 2017, uma metanálise reuniu 9 estudos e essa redução de NR não foi observada, contudo, uma melhora da função ventricular de longo prazo no grupo stent adiado foi apontada.13

Outras estratégias como utilização de drogas intracoronárias (adenosina, bloqueadores do canal de cálcio e nitropussiato) e de inibidores da glicoproteína IIb/IIIa mostraram algum benefício na prevenção e tratamento do NR e necessitam de maiores estudos.14

O fenômeno de NR é o maior desafio da reperfusão primária e apesar dos esforços, o conhecimento pouco evoluiu no tratamento ou prevenção dessa condição. Escores angiográficos tornam a avaliação da cineangiocoronariografia mais objetiva e, como demonstrado nesse manuscrito, a associação de escores clássicos (SYNTAX, Gensini, Carga trombótica) colabora na discriminação dos pacientes com pior prognóstico, potencialmente implicando em condutas a serem tomadas para otimizar o tratamento e melhorar desfechos.

Minieditorial referente ao artigo: O Escore Gensini e a Carga Trombótica Adicionam Valor Preditivo ao Escore SYNTAX na Detecção de No-Reflow após Infarto do Miocárdio

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Relationship between microvascular obstruction and adverse events following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: an individual patient data pooled analysis from seven randomized trials. Eur Heart J 2017;38(47):3502-10. Balk M Gomes HB Quadros AS de Saffi MAL Leiria TLL Comparative Analysis between Transferred and Self-Referred STEMI Patients Undergoing Primary Angioplasty Arq Bras Cardiol 2019 112 4 402 407 4. Balk M, Gomes HB, Quadros AS de, Saffi MAL, Leiria TLL. Comparative Analysis between Transferred and Self-Referred STEMI Patients Undergoing Primary Angioplasty. Arq Bras Cardiol. 2019;112(4):402-7. Ramjane K Han L Jin C The diagnosis and treatment of the no-reflow phenomenon in patients with myocardial infarction undergoing percutaneous coronary intervention Exp Clin Cardiol 2008 13 3 121 128 5. Ramjane K, Han L, Jin C. The diagnosis and treatment of the no-reflow phenomenon in patients with myocardial infarction undergoing percutaneous coronary intervention. Exp Clin Cardiol. 2008;13(3):121–8. Celebi S Celebi OO Cetin S Cetin HO Tek M Gokaslan S The Usefulness of Admission Plasma NT-pro BNP Level to Predict Left Ventricular Aneurysm Formation after Acute ST-Segment Elevation Myocardial Infarction Arq Bras Cardiol 2019 113 6 1129 1137 6. Celebi S, Celebi OO, Cetin S, Cetin HO, Tek M, Gokaslan S, et al. The Usefulness of Admission Plasma NT-pro BNP Level to Predict Left Ventricular Aneurysm Formation after Acute ST-Segment Elevation Myocardial Infarction. Arq Bras Cardiol. 2019;113(6):1129–37. Papapostolou S Andrianopoulos N Duffy SJ Brennan AL Ajani AE Clark DJ Long-term clinical outcomes of transient and persistent no-reflow following percutaneous coronary intervention (PCI): a multicentre Australian registry EuroIntervention 2018 14 2 185 193 7. Papapostolou S, Andrianopoulos N, Duffy SJ, Brennan AL, Ajani AE, Clark DJ, et al. Long-term clinical outcomes of transient and persistent no-reflow following percutaneous coronary intervention (PCI): a multicentre Australian registry. EuroIntervention. 2018;14(2):185–93. Matos LCV Carvalho LS Modol Ro Simone Santos S Silva JCQ Almeida OLR Gensini Score and Thrombus Burden Add Predictive Value to the SYNTAX Score in Detecting No-Reflow after Myocardial Infarction Arq Bras Cardiol 2021 116 3 466 472 8. Matos LCV, Carvalho LS, Modol Ro, Simone Santos S, Silva JCQ, Almeida OLR, et al. Gensini Score and Thrombus Burden Add Predictive Value to the SYNTAX Score in Detecting No-Reflow after Myocardial Infarction. Arq Bras Cardiol. 2021; 116(3):466-472. Rampidis GP Benetos G Benz DC Giannopoulos AA Buechel RR A guide for Gensini Score calculation Atherosclerosis 2019 287 181 183 9. Rampidis GP, Benetos G, Benz DC, Giannopoulos AA, Buechel RR. A guide for Gensini Score calculation. Atherosclerosis. 2019;287:181–3. Gibson CM de Lemos JA Murphy SA Marble SJ McCabe CH Cannon CP Combination Therapy With Abciximab Reduces Angiographically Evident Thrombus in Acute Myocardial Infarction: A TIMI 14 Substudy Circulation 2001 103 21 2550 2554 10. Gibson CM, de Lemos JA, Murphy SA, Marble SJ, McCabe CH, Cannon CP, et al. Combination Therapy With Abciximab Reduces Angiographically Evident Thrombus in Acute Myocardial Infarction: A TIMI 14 Substudy. Circulation. 2001;103(21):2550–4. Topol EJ Yadav JS Recognition of the Importance of Embolization in Atherosclerotic Vascular Disease Circulation 2000 101 5 570 580 11. Topol EJ, Yadav JS. Recognition of the Importance of Embolization in Atherosclerotic Vascular Disease. Circulation. 2000;101(5):570–80. Carrick D Oldroyd KG McEntegart M Haig C Petrie MC Eteiba H A Randomized Trial of Deferred Stenting Versus Immediate Stenting to Prevent No- or Slow-Reflow in Acute ST-Segment Elevation Myocardial Infarction (DEFER-STEMI) J Am Coll Cardiol 2014 63 20 2088 2098 12. Carrick D, Oldroyd KG, McEntegart M, Haig C, Petrie MC, Eteiba H, et al. A Randomized Trial of Deferred Stenting Versus Immediate Stenting to Prevent No- or Slow-Reflow in Acute ST-Segment Elevation Myocardial Infarction (DEFER-STEMI). J Am Coll Cardiol. 2014;63(20):2088–98. Qiao J Pan L Zhang B Wang J Zhao Y Yang R Deferred Versus Immediate Stenting in Patients With ST - Segment Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis J Am Heart Assoc 2017 6 3 e004838 13. Qiao J, Pan L, Zhang B, Wang J, Zhao Y, Yang R, et al. Deferred Versus Immediate Stenting in Patients With ST - Segment Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2017;6(3):e004838. Rezkalla SH Stankowski RV Hanna J Kloner RA Management of No-Reflow Phenomenon in the Catheterization Laboratory JACC: Cardiovasc Interv 2017 10 3 215 223 14. Rezkalla SH, Stankowski RV, Hanna J, Kloner RA. Management of No-Reflow Phenomenon in the Catheterization Laboratory. JACC: Cardiovasc Interv. 2017;10(3):215–23. Short Editorial Angiographic Scores in Prediction of No-Reflow, Myocardial Injury May not end with Reperfusion Tamazato Adriano Ossuna 1 2 0000-0001-6166-9777 Tamazato Thais Chang Valente 1 2 0000-0002-4762-0579 Bezerra Cristiano Guedes 1 2 3 Salvador BA Brazil Hospitais Aliança, São Rafael, Cardiopulmonar – Rede D’Or, Salvador, BA - Brazil. Salvador BA Brazil Hospital Ana Nery, Salvador, BA - Brazil. Salvador BA Brazil Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA - Brazil. Mailing Address: Cristiano Guedes Bezerra • Universidade Federal da Bahia - Hemodinâmica e Cardiologia Intervencionista R. Dr. Augusto Viana, s/n. Postal Code 40110-060, Canela, Salvador, BA – Brazil. E-mail: cristianoguedes@live.com Keywords Percutaneous Coronary Intervention/methods Myocardial Infarction Atherosclerosis Plaque Atherosclerotic Embolization Therapeutic

The ST segment elevation infarction (STEMI) is usually precipitated by the rupture or erosion of an atherosclerotic plaque and the consequent formation of an occlusive thrombus. Early percutaneous coronary intervention is the treatment of choice for providing a more complete revascularization and less bleeding complications when compared to fibrinolysis.1,2

In the last decades, we observed a substantial development in the pharmacological and invasive treatments of STEMI, which significantly reduced early mortality. Several variables affect clinical outcomes, including patient age, time to reperfusion, angiographic complexity and the occurrence or not of the no-reflow (NR) phenomenon during percutaneous intervention.3,4 NR is defined by inadequate myocardial perfusion in a given territory, in the absence of mechanical obstruction of the epicardial coronary5 and is associated with a worse clinical prognosis.6,7

In this edition, the “Arquivos Brasileiros de Cardiologia” publish the article “Gensini Score and Thrombus Burden Add Predictive Value to the SYNTAX Score in Detecting No-Reflow after Myocardial Infarction”, the authors evaluated the angiography of 481 consecutive patients admitted by STEMI and calculated the SYNTAX and modified Gensini scores, in addition to assessing thrombotic burden objectively. A better accuracy of the prediction of the NR phenomenon was found when the combination of the three scores was used.8

The Gensini score was first described in 1975 and takes into account 3 parameters for each coronary lesion: severity of the obstruction, multiplied by a factor according to the importance of the region irrigated by the artery and adjusted by the presence of collaterals;9 includes stenoses less than 25% and is, therefore, more sensitive to partial obstructions than SYNTAX SCORE. The objective quantification of thrombotic load is determined by the TIMI scale from 0 to 5, where 0 is the absence of a thrombus and 5 is the presence of an occlusive thrombus.10

The relationship of these angiographic scores to the presence of NR phenomenon makes physiopathological sense, because although it is not fully clarified, the NR phenomenon in patients undergoing primary percutaneous intervention has distal microembolization as one of its causes,11 which depends on the angiographic variables studied by the authors. In the published study, no data were reported about the procedures (thrombus aspiration, stents, post-dilation), medications used and reversibility of the phenomenon that also significantly impact the angiographic and clinical prognosis.

The act of predicting a potentially catastrophic phenomenon is important when it impacts on changing strategy before it occurs. The DEFER-STEMI study, published in 2014, touched precisely on this point: a proof-of-concept trial that assessed the impact of delayed-stent (with the artery already reperfused by balloon or thrombus aspiration) in order to reduce the incidence of NR and the size of the infarction, assessed by magnetic resonance imaging - the rationale is that delayed stent may allow time for the action of antithrombotic drugs, reduced thrombus burden and consequently less NR and smaller infarcted area. In fact, in this study, there was a significant reduction in NR (from 14% to 2% in the stent-delayed group) and an improvement in the myocardial salvage rate in 6 months.12 Later, in 2017, a meta-analysis brought together 9 studies and the reduction in NR was not observed, however, an improvement in long-term ventricular function in the delayed stent group was pointed out.13

Other strategies such as the use of intracoronary drugs (adenosine, calcium channel blockers and nitroprusside) and glycoprotein IIb/IIIa inhibitors have shown some benefit in the prevention and treatment of NR and need further studies.14

The NR phenomenon is the greatest challenge of primary reperfusion and despite efforts; knowledge has evolved little in the treatment or prevention of this condition. Angiographic scores, which make the assessment of cineangiocoronariography more objective, contribute to the discrimination of patients with a worse prognosis, particularly when the association of classic scores is used (SYNTAX, Gensini, Thrombotic load), as demonstrated in this article. Recognizing these patients can lead to optimization of treatment and improvement of outcomes.

Short Editorial related to the article: Gensini Score and Thrombus Burden Add Predictive Value to the SYNTAX Score in Detecting No-Reflow after Myocardial Infarction