Clinical and Angiographic Predictors of No-Reflow Phenomenon after Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients; Mansoura Experience
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASEPraveen Nagula
MITRAL VALVE ANATOMY , M MODE FINDINGS IN MITRAL STENOSIS,EVALUATION OF THE SEVERITY OF LESION,CALCIFIC MS,CCMA,CONGENITAL LESIONS,GUIDELINES ALL IN DETAIL....
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASEPraveen Nagula
MITRAL VALVE ANATOMY , M MODE FINDINGS IN MITRAL STENOSIS,EVALUATION OF THE SEVERITY OF LESION,CALCIFIC MS,CCMA,CONGENITAL LESIONS,GUIDELINES ALL IN DETAIL....
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
Fourth Universal Definition Of Myocardial Infarction (2018)magdy elmasry
Reasons for the elevation of cardiac troponin values
because of myocardial injury.
Spectrum of myocardial injury, ranging from no injury to myocardial infarction. Criteria For MI.Types of MI.Myocardial Infarction with Non-Obstructive Coronary Arteries(MINOCA)
Reverse Takotsubo Cardiomyopathy Following General AnaesthesiaPremier Publishers
Reverse takotsubo cardiomyopathy(r-TTC) is a rare condition in which regional wall motion abnormalities affect the basal segments of left ventricle in absence of significant coronary artery disease. The Diagnosis is established by characteristic echocardiographic findings, clinical manifestations, and laboratory features. In this report we demonstrate a case of general anaesthesia induced cardiomyopathy in 21 years old female.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
2. INTRODUCTION
IMPORTANCE
DEFINITION
HISTORICAL BACKGROUND
INCIDENCE
TYPES OF NO REFLOW
ASSESSMENT AND PREDICTION OF CORONARY NO-REFLOW
PHENOMENON
CLINICAL PREDICTORS OF NO-REFLOW PHENOMENON
ANGIOGRAPHIC PREDICTORS OF NOREFLOW PHENOMENON
BIOCHEMICAL MARKERS PREDICTING NOREFLOW PHENOMENON
IMAGING MODALITIES TO ASSESS AND PREDICT NOREFLOW
PHENOMENON
SCORING SYSTEMS
PROPHYLAXSIS
INITIAL EVALUATION ON CATHETER LABORATORY
DIFFERENTIAL DIAGNOSIS OF CORONARY SLOW FLOW
PHENOMENA
TREATMENT
REFRACTORY NO-REFLOW
PROGNOSIS
AIM OF STUDY
STUDY DESIGN
INCIDENCE OF NOREFLOW IN OUR STUDY
CONCLUSIONS
RECOMMENDATION
STUDY LIMITATIONS
NO-REFLOW CASE PRESENTATION
3. • The key of acute STEMI treatment is to quickly restore the IRA
perfusion, resulting in the slogan ‘Time is the Myocardium, Time is
Life’. As the body has a complex regulatory mechanism, where, on the
one hand, the necrotic myocardium cannot be restored, and on the
other hand, it is accompanied with reperfusion injuries and even the
no-reflow phenomenon, the occurrence and development of the no-
reflow phenomenon contain reperfusion injuries
4. • No-reflow phenomenon is a common and severe complication of
patients with acute myocardial infarction AMI after direct PCI. As
its occurrence hinders the effective myocardial reperfusion, it has
become an independent predicative indicator for short-term
prognosis as well as long-term heart failure, arrhythmia, sudden
cardiac death and other cardiac events
5. • No-reflow phenomenon is characterized by the failure of
myocardial reperfusion despite the absence of mechanical coronary
obstruction (Rossington, Sol et al. 2020). (Ito, Tomooka et al. 1992)
first described the phenomenon of ‘no reflow’ in humans with acute
myocardial infarction, whereby perfusion is not re-established
despite patency of the epicardial coronary artery.
6. Prediction of patients at risk for no-reflow before PCI may be
beneficial from the perspective of prevention. Risk awareness will lead to
the use of certain techniques that may ameliorate the degree of no-reflow
No reflow (NR) defined as final thrombolysis in myocardial
infarction (TIMI) flow <III or TIMI III flow with TIMI myocardial
blush grade (TMBG) 0 or 1 in absence of mechanical obstruction. TIMI
flow grade is the easiest and most commonly used method of
evaluating success of PCI in the setting of STEMI
7. • The TIMI grade flow is classified as follows: TIMI-0 indicates there
is no antegrade flow beyond the point of occlusion, TIMI-1 indicates
there is a faint antegrade coronary flow beyond the occlusion with an
incomplete filling of the distal coronary bed, TIMI-2 indicates there
is delayed or sluggish antegrade flow with complete filling of the
distal territory, and TIMI-3 indicates normal flow with complete
filling of the distal territory (Avci, Yildirim et al. 2018).
TIMI Blood Flow Grades
8. • In primary angioplasty, myocardial blush grade independently predicts
long-term mortality, TIMI flow, and LV function. TIMI frame counts
and myocardial blush are more reproducible and more accurate than
TIMI flow grades. A combination of TIMI flow and TIMI myocardial
perfusion grade before and after PCI has been described (Angiographic
Perfusion Score) as a single myocardial perfusion grade
Myocardial Blush
9. Angiographic assessment of myocardial perfusion: TIMI myocardial perfusion (TMP) grading
system.
Permission reproduced from (Appleby, ANGEJA et al. 2001), BMJ Publishing Group Ltd.
10.
11. • The first clinical observation of coronary no-reflow was reported by
Schofer et al.in 1985.
• In 1989, Wilson et al. observed persistent angina with ST elevation in
association with a slow angiographic antegrade flow despite a widely
patent angioplasty site in five patients immediately after PTCA of a
thrombus containing lesion.
• In 1991,Pomerantz et al. reported five more cases of noreflow
successfully treated by intracoronary verapamil.
• the first clinical case of no-reflow during PTCA for acute myocardial
infarction was reported by Feld et al. in 1992
12. Reflow is an under-reported complication. A low incidence of 1–3%
has been recorded in large registries based on TIMI flow grade,
myocardial blush grade and ST resolution. Modern more sensitive
methods of assessing no reflow and microcirculatory dysfunction include
myocardial contrast echocardiography (MCE) and cardiac magnetic
resonance imaging (CMRI), which have recorded a higher incidence (10–
30%) (Gupta and Gupta 2016).
13. NR has a multifactorial aetiology and broadly can be defined by four
distinct groups:
I. Distal atherothrombotic embolisation
II. Ischaemic injury
III. Reperfusion injury
IV. Susceptibility of coronary micro-circulation to injury. Distal
embolization is a result of debris (thrombi, endothelial cells and
lipid matrix) migrating downstream from the primary lesion, leading
to microvascular obstruction and further injury
14. Sustained
Result of anatomical irreversible changes of coronary microcirculation
Undergo unfavorable LV remodeling
Reversible
Result of functional & thus reversible changes of microcirculation
Maintain their left ventricle volumes unchanged over time
16. Clinical predictors
Age
Family history of CAD
Pre infarction angina
Heart rate
Killip class
Delayed reperfusion
Low preoperative systolic blood
pressure
Smoking
Atrial fibrillation
Shock index
CHA2DS2–VASc score
Psychological distress
Sex hormones
17. Angiographic Predictors
TIMI blood flow grades
The corrected TIMI frame count
(CTFC)
Myocardial blush
Lesion length and reference lumen
diameter
Thrombus burden
Coronary artery ectasia
Culprit artery
Syntax score
Stent overexpansion
Saphenous vein coronary bypass grafts
Collateral Flow Grade
Chronic Total Occlusion
Bifurcation lesions
Angiographic predictors
Air embolism
Contrast agent
Iatrogenic Dissection of the Left Main
Coronary Artery
Treatment of coronary in-stent
restenosis with a paclitaxel-coated
balloon catheter
Plaque prolapse
Lesion Morphology
OCT
Rotational atherectomy
orbital atherectomy
Intravascular lithotripsy.
18. Biomarkers
Cardiac biomarkers
The blood glucose level
Serum uric acid
CBC Parameters
a) hemoglobin level
b) RDW levels
c) Polycythemia vera
d) Platelet Indices
e) Leukocyte Indices
f) The neutrophil lymphocyte
ratio
Hs-CRP
LDH
D-dimer
Biomarkers
Dyslipidemia
Serum B-type natriuretic peptide
Renal impairment
Serum bilirubin levels
Fibrinogen
Cystatin C
Plasma myeloperoxidase levels
Microalbuminuria
Serum endocan levels
Clot permeability
Soluble CD40b ligand level
Angiopoietin-Like 4 Serum Levels
MicroRNAs
19. Imaging Modalities Predictors
Myocardial contrast echocardiography
Left Ventricular Ejection Fraction
EAS index
Speckle-tracking echocardiography
Magnetic resonance imaging
Cardiac computed tomography (CCT)
Nuclear magnetic imaging
Electrocardiographic predictors
higher Q/R in admission ECG
20. Scoring Systems
(Bakr, Roshdy et al. 2017) suggested a weighted scoring system , to predict the
development of no reflow phenomenon during primary percutaneous coronary
intervention in patients with acute myocardial infarction. An 8 variable scoring
system was constructed as follows age above 60 years old 1 point, delayed
reperfusion time more than 4hrs 2 points, large luminal diameter ≥2.8 mm 2
points, long target lesion ≥20 mm 4 points, high thrombus burden 1 point, initial
TIMI flow ≤ 1 is 3 points, positive Ck-Mb on admission 2 points and elevated D-
dimer ≥ 500 ng/ml 1 point, with final total score 16 points. scoring 10 points or
more are most likely to have no reflow phenomenon, test sensitivity was 86% and
specificity was 73%.
21. Strategies For Prevention How To Apply
Aggressive lifestyle modification
Cessation of smoking
Exercise regularly
Avoid stress
Control blood pressure
BB ,ACEI ,CCB
Strict control of blood sugar
Oral hypoglycemic or insulin
Treatment of dyslipidemia Intensive statin therapy
Preoperative loading of antiplatelet
Ticagrelor loading
Anti-ischemic
Chronic Pre-treatment With Beta
Blockers on no-reflow phenomenon
IV metoprolol
22. Coronary vasodilator Intracoronary nicorandil
Revascularization
Shortened door-to-balloon times
Primary stenting
Avoidance of high pressure stent
deployment
Avoid long stents
Mechanical and Device Therapies
Embolic Protection Devices
Thrombectomy before the
intervention
'MAP strategy'
Maximum aspiration of athero-
thrombus
Adjuvant utilization of GP IIb/IIIa
inhibitor
Prolonged inflation of the
balloon/stent
Deferred Stenting
delaying a stent implantation after
mechanical flow restoration,
vasodilators, antithrombotic drugs
(GP IIb/IIIa inhibitors) and statins.
Ischemic preconditioning
4 × 5 min inflations/deflations of
cuff on upper arm before
thrombolysis
23. Coronary slow flow
phenomena
What to do
In situ thrombus
Manual catheter aspiration.
Additional angioplasty and stenting might be necessary.
Dissection additional stenting
Severe spasm
Intracoronary nitroglycerin (100 mcg/cc) can be given until the vasospasm
is relieved
Plaque rupture
Manual catheter aspiration
Additional angioplasty and stenting might be necessary.
Distal athero-
thrombo-
embolization.
Additional anticoagulation with more heparin and/or gp receptor IIB/IIIA
inhibitors should be started.
Rechecking activated clotting time (act) levels is prudent.
24.
25. Exclude dissection, thrombus, spasm at lesion site (IVUS, distal contrast
injections, and/or translesion pressure gradient may be useful).
UFH (weight-adjusted i.v. bolus during PCI of 70-100 IU/kg, or 50-70
IU/kg in combination with a GP IIb/IIIa inhibitor; activated clotting time target
range of 250-350 s, or 200-250 s if a GP IIb/IIIa inhibitor is given) is recommended
in patients undergoing PCI ,class I level of evidence A in 2020 ESC Guidelines for
the management of acute coronary syndromes in patients presenting without
persistent ST-segment elevation: (Collet, Thiele et al. 2020).
26. (Hashemifard 2009) demonstrated when no reflow occurs in the right
coronary artery or inferior distribution, atropine therapy may be necessary to treat
the reflex hypotension and bradycardia that may occur.
Maintain adequate perfusion pressure with intravenous fluids,
vasopressors, inotropes, and IABP if necessary as routine use of IABP in patients
with CS and no mechanical complications due to ACS is not recommended class
III level of evidence B in 2020 ESC Guidelines for the management of acute
coronary syndromes in patients presenting without persistent ST-segment
elevation (Collet, Thiele et al. 2020) . Administer intracoronary nitroglycerin
(100–200 µg up to four doses) to exclude epicardial spasm. Consider
administering a glycoprotein IIb/IIIa receptor inhibitor .
29. Non Pharmacological Interventions
Induced Hypothermia
Ischemic Post-conditioning
Intracoronary Transfusion Of Autologus
Blood
Intracoronary Delivery Of Mitochondria
Embryonic Haemangioblasts
30. Alternative Therapies For Treating No-reflow
Diagnostic Ultrasound And Microbubbles
Treatment Improves Outcomes Of Coronary No-
reflow In Canine Models By Sonothrombolysis
Intra-aortic Balloon Pump
Coronary Artery Bypass Graft Surgery
31. Newer Drugs And Prospectives Under Investigation
Cyclosporine-A
Glucagon-like Peptide (GLP)-1 Analog
Bendavia
Atrial Natriuretic Peptide
Fx 06
Pexelizumab
Eniporide
Cp-4715
Imatinib
Pyrrolidine Dithiocarbamate
33. It was defined as persistent TIMI flow grade (TFG) ≤2 despite intracoronary
administration of at least one other pharmacologic intervention. Intracoronary
epinephrine may become an effective alternative in patients suffering refractory no-
reflow following primary PCI, at a dose of at least 100 μg (range, 100–400 μg) given
through the central lumen of an over-the-wire balloon catheter (Aksu, Guler et al. 2015).
Epinephrine causes potent coronary vasodilator effect via β2 receptor activation, in
addition to its chronotropic and inotropic effects on the heart. Thus, it should not be
confusing that intracoronary epinephrine may reveal a beneficial effect on the
prevention of the no-reflow in the patients with STEMI.
34. (Khuyag, Chimed et al. 2017) demonstrated that in patients with
STEMI who underwent primary PCI for reperfusion, a coronary no-
reflow phenomenon is a strong and independent predictor of 30-day
mortality.
35. This study is conducted to identify simple clinical factors,
laboratory, angiographic findings and procedural features that
predict no-reflow phenomenon in patients with STEMI who
undergo PCI in cardiovascular medicine department at Mansoura
Specialized Medical Hospital.
36. We compared the predictor data in subjects with normal reflow
and no reflow after PCI. No reflow phenomenon is diagnosed based
on angiographical evidence of reopening of the occluded coronary
artery with no evidence of flow-limiting residual stenosis (<50%),
dissection, vessel spasm or thrombus burden. Angiographical
documentation of thrombolysis in myocardial infarction (TIMI) flow
grade ≤II. A TIMI flow grade III with a myocardial blush grade 0 or I,
at least 10 min after the end of the PPCI procedure
37. Enrollment
Assessed for eligibility
(n=444)
Excluded (n=26)
Not meeting inclusion criteria (n= 26)
Studied groups
(n=418)
TIMI flow
No reflow
n=61(14.6%)
(TIMI ≤2)
Reflow
n=357(85.4%)
(TIMI =3)
Mortality
n=18(5%)
Mortality
n=6(9.8%)
38. total number
n=418
No reflow
)N=61
Reflow
)N=357)
test of
significance
p-value
Age/years
mean±SD
55.88±8.33 54.88±11.61 56.05±7.65 t=1.04 p=0.317
Age/years
<60
≥60
264
154
N (%)
37(60.7)
24(39.3)
N (%)
227(63.6)
130(36.4)
χ2=0.192 p=0.661
Sex
Male
Female
339
79
52(85.2)
9(14.8)
287(80.4)
70(19.6)
χ2=0.801 p=0.371
Total number
=418
No reflow
N=61(%)
Reflow
N=357(%)
test of significance p-value
Hypertension
-VE
+VE
218
200
29(47.5)
32(52.5)
189(52.9)
168(47.1)
χ2=0.609 p=0.489
DM
-ve
+ve
225
193
33(54.1)
28(45.9)
192(53.8)
165(46.2)
χ2=0.002
p=0.963
Smoking
-ve
+ve
291
127
40(65.6)
21(34.4)
251(70.3)
106(29.7)
χ2=0.552 p=0.457
Family history of
IHD
-ve
+ve
346
72
46(75.4)
15(24.6)
300(84.0)
57(16.0)
χ2=2.72 p=0.09
Association Between Medical History And No Reflow Among Studied Cases
Association Between Demographic Characteristics And No Reflow Among Studied Cases.
39. Total number
No reflow
)N=61
Reflow
)N=357)
Test of
significance
p value
DBP 76.12±8.28 75.90±8.44 76.15±8.26 t=0.152 P=0.828
SBP 123.99±10.39 123.77±10.03 124.03±10.46 t=0.193 P=0.857
Pre-operative HR 76.38±9.91 77.09±11.95 76.26±9.53 t=0.254 P=0.542
Pre-infarction angina 278 29(47.5) 249(69.7) χ2=11.53 p=0.001*
Pre-operative KILLIP
class
1
2
3
4
396
18
3
1
59(96.7)
2(3.3)
0(0.0)
0(0.0)
337(94.4)
16(4.5)
3(0.80)
1(0.30)
MC P=0.828
CHA2DS2-VASc Risk
Criteria
1.56±1.12 2.33±1.01 1.42±1.08 t=6.09 p<0.001*
Association Between No Reflow And Clinical Characteristics Among Studied Cases.
41. Total
number
No reflow
N=61(%)
Reflow
N=357(%)
Test of
significance
P-value
Ticagrelor or Clopidogrel
loading
Ticagrelor
Clopidogrel
23
395
5(8.2)
56(91.8)
18(5.0)
339(95.0) χ2=0.997 P=0.318
Prior statin therapy
-ve
+ve
260
158
35(57.4)
26(42.6)
225(63.0)
132(37.0)
χ2=0.707
p=0.400
Dose & type of prior statin
therapy
Rosuvastatin
Simvastatin
Atorvastatin
N=158
6
27
125
N=26
1(3.8)
3(11.5)
22(84.6)
N=123
5(3.8)
24(18.2)
103(78.0)
MC p=0.712
Drug Use Among Studied Groups
42. Total number
=418
No reflow
N=61(%)
Reflow
N=357(%)
test of significance p-value
Infarction location
Anterior 290 46(75.4) 244(68.3)
MC P=0.316
Inferior 89 12(19.7) 77(21.6)
Lateral 21 3(4.9) 18(5.0)
other locations 18 0(0.0) 18(5.0)
Presence of pathologic Q
waves in admission ECG
207 44(72.1) 163(45.7) χ2=14.61 p<0.001*
Absence of STR≥50
–VE
+VE
234
184
15(24.6)
46(75.4)
219(61.3)
138(38.7)
χ2=28.56 P<0.001*
Association Between ECG Changes And No Reflow Among Studied Cases.
43. Total Number
=418
No Reflow
N=61(%)
Reflow
N=357(%)
Test Of
Significance
P-value
EF %
Mean ± Sd
47.29±5.53 45.67±5.02 47.57±5.57 T=2.49 P=0.013*
Association Between Echocardiographic Changes And No Reflow Among Studied Cases
44. Association Between No Reflow And Initial TIMI Flow, TFC, Myocardial Blush And Collateral Flow Grade Among
Studied Cases
Total
number
=418
No reflow
N=61(%)
Reflow
N=357(%)
test of
significance
p-value
Initial TIMI
flow
0/1
2/3
88
330
30(49.2)
31(50.8)
58(16.2)
299(83.8)
χ2=33.99 P<0.001*
TFC 21.64±8.20 36.41±9.95 19.11±4.27 t=14.58 p<0.001*
Myocardial
blush grade
<2
≥2
61
357
60(98.4)
1(1.6)
1(0.3)
356(99.7)
FET p<0.001*
Collateral
flow grade
<2
≥2
53
365
38(62.3)
23(37.7)
15(4.2)
342(95.8)
χ2=158.803 p<0.001*
45. Total number
=418
No reflow
)N=61)
Reflow
)N=357)
test of
significance
p-value
Infarction related artery
LAD
RCA
LCX
282
106
30
43(70.5)
12(19.7)
6(9.8)
239(66.9)
94(26.3)
24(6.7)
χ2=1.71 p=0.425
Culprit lesion length 21.40±6.75 27.75±8.49 20.33±5.77 t=18.97 p<0.001*
Vessel diameter 3.13±0.23 3.32±0.26 3.10±0.21 t=12.56 p<0.001*
Thrombus grade
0
1
2
3
4
5
3
9
22
249
108
27
0(0.0)
0(0.0)
1(1.6)
22(36.1)
23(37.7)
15(24.6)
3(0.8)
9(2.5)
21(5.9)
227(63.6)
85(23.8)
12(3.4)
MC p<0.001*
Thrombus grade
Grade 0(Nil)
Low (grade 1/2)
Moderate (grade 3)
High (grade 4/5)
3
31
249
135
0(0.0)
1(1.6)
22(36.1)
38(62.3)
3(0.8)
30(8.4)
227(63.6)
97(27.2)
MC P<0.001*
<4
≥4
283
135
23(37.7)
38(62.3)
260(72.8)
97(27.2)
χ2=29.39 p<0.001*
Syntax score
mean±SD
23.48±3.89 27.46±3.52 22.80±3.54
t=9.51 P<0.001*
Multivessel disease 132 35(57.4) 97(27.2) χ2=22.0 p<0.001*
Lesion type
Eccentric
Concentric
221
197
28(45.9)
33(54.1)
193(54.1)
164(45.9)
χ2=1.39 p=0.238
Type of occlusion
Total
Tappered
Subtotal
Cut off
27
77
174
140
25(40.9)
9(14.8)
5(8.2)
22(36.1)
2(0.6)
68(19.0)
169(47.3)
118(33.1)
MC P<0.001*
Lesion location
Proximal
Ostial
Mid
Distal
199
16
134
69
34(55.7)
2(3.3)
22(36.1)
3(4.9)
165(46.2)
14(3.9)
112(31.4)
66(18.5)
MC p=0.06
Association
Between
No
Reflow
And
Lesion
Characteristics
Among
Studied
Cases.
46.
47. Total
number
N=418
No reflow
N=61
Reflow
)N=357)
test of
significance
P Value
Direct stenting
no
Yes
137
281
26(42.6)
35(57.4)
111(31.1)
246(68.9)
χ2=3.14 P=0.076
Pre-balloon
dilatation with
stenting
74 18(29.5) 56(15.7) χ2=6.83 p=0.009*
Post-balloon
dilatation
25 12(19.7) 13(3.6) χ2=23.81 p<0.001*
Maximal inflation
pressure of stent
14.93±1.64 16.42±1.99 14.68±1.43 t=2.5 p<0.001*
DES
BMS
414
4
60(98.4)
1(1.6)
354(99.16)
3(0.84)
FET p=0.427
Number of stents
1
2
3
4
350
60
7
1
44(72.1)
12(19.7)
4(6.6)
1(1.6)
306(85.7)
48(13.4)
3(0.8)
0(0.0)
MC p<0.001*
Aspiration
thrombectomy
36 15(24.6) 21(5.9) χ2=23.17 p<0.001*
Use of GP 2b3a
inhibitor
39 37(60.7) 2(0.6) χ2=222.41 p<0.001*
Contrast volume 126.48±50.97 178.03±68.55 117.68±41.45 t=17.81 p<0.001*
Technique Of Reperfusion Among Studied Groups.
48. Total number
No reflow
)N=61)
Reflow
)N=357)
Test of
significa
nce
p-value
Total ischemic
time (min) from
symptom onset to
ballon crossing in
PPCI
97.29±70.30 135±114.3 88.96±53.32 t=3.46 p=0.001*
Total ischemic
time (min) from
symptom onset to
successfull
reperfusion by
thrombolysis
141.05±103.45 177.86±140.94 129.07±86.73 t=1.55 p=0.126
Total ischemic
time (min) in
rescure PCI
344.38±147.74 368±115.34
333.64±160.8
1
t=0.743 p=0.461
Association Between No Reflow And Total Ischemic Time Results Among Studied Cases
49. Total
number
n=418
No reflow
N=61(%)
Reflow
N=357(%)
Test of
significance
p value
Primary PCI 178 32(52.5) 146(40.9) χ2=2.85 P=0.09
Pharmacoinvasive with successful
SK
113 9(14.8) 104(29.1) χ2=5.46 p=0.019*
Rescue PCI 48 15(24.6) 33(9.2) χ2=12.07 p=0.001*
Failed SK then early elective PCI 12 1(1.6) 11(3.1) χ2=0.388 P=0.533
Successful SK then early elective
PCI
47 3(4.9) 44(12.3) χ2=0.187 p=0.09
Missed STEMI then early elective
PCI
20 1(1.6) 19(5.3) χ2=0.356 P=0.213
Association Between No Reflow And Methods Of Reperfusion Among Studied
Cases.
52. MACE N=418
No reflow
)N=61)
Reflow
)N=357)
test of significance
recurrent chest pain 93 21(34.4) 72(20.2) P=0.013*
re-infarction 43 18(29.5) 25(7.0) P<0.001*
ventricular arrythmia 51 10(16.4) 41(11.5) p=0.236
heart failure 34 9(14.8) 25(7.0) p=0.04*
all cause mortality 25 8(13.1) 17(4.8) p=0.01*
MACE Distribution Within 180 Days Among Studied Groups.
53. ROC Curve of significant predictors of no-
reflow with cut off point less than, indicate
positive results.
ROC Curve of significant predictors of no-
reflow with cut off point greater than, indicate
positive results.
54. Test Result Variable(s) AUC P
Asymptotic 95% Confidence
Interval Cut off
point
Sensitivity
(%)
Specificity
(%)
Lower Bound Upper Bound
age/years
0.530 0.460 0.443 0.616 60.5 70.0 26.3
total ischemic time (min) from
symptom onset to ballon
crossing in PPCI. 0.609 0.054 0.495 0.723 150 91.0 39.1
CKMB (IU/L) 0.607 0.059 0.492 0.722 237.5 74.5 46.9
PDW(fl) 0.539 0.495 0.429 0.648 14.05 70.3 40.6
Syntax score 0.870 <.001* 0.792 0.948 27.50 85.5 81.2
Culprit lesion length 0.790 <0.001* 0.695 0.886 24.5 86.1 61.3
TFC 0.916 <0.001* 0.852 0.981 25.5 90.3 80.6
Contrast volume 0.812 <0.001* 0.717 0.907 205.0 95.8 51.6
EF% 0.601 <0.001* 0.524 0.679 46.5 63.3 51.5
Thrombus grade 0.741 <0.001* 0.635 0.846 4 72.4 69.4
Maximal inflation pressure of
stent
0.736 <0.001* 0.630 0.841 15.0 72.4 69.4
CHA2DS2-VASc Risk Criteria
0.761 <0.001* 0.672 0.850 2 86.2 51.2
Validity Of Significant Indices In Differentiating Cases With No Reflow
55. Predictors β p
Odds ratio
(95% CI)
EF % -0.071 0.013* 0.931(0.881-0.985)
Blood glucose level per PCI 0.001 0.147 1.00(1.00-1.002)
Initial time flow -2.70 0.116 0.067(0.002-1.95)
Myocardial blush grade -5.06 <0.001* 0.006(0.001-0.077)
Collateral flow grade -2.35 0.014* 0.05(0.014-0.625)
Culprit lesion length 0.095 0.007* 1.09(1.026-1.178)
Vessel diameter 1.64 0.118 5.13(0.659-39.96)
Contrast volume 0.01 0.02* 1.01(1.002-1.02)
TFC 0.245 <0.001* 1.278(1.189-1.374)
Aspiration thrombectomy 1.65 <0.001* 5.19(2.32-11.65)
Thrombus grade ≥ 4 1.19 <0.001* 3.29(2.18-4.98)
Number of stents 0.653 0.03* 1.92(1.07-3.45)
Type of occlusion 1.05 0.06 1.0(0.89-4.2)
Total ischemic time (min) from
symptom onset to ballon crossing in PCI
0.519 0.002* 1.68(1.21-2.33)
Pharmacoinvasive with successful SK -2.09 0.047* 0.25(0.03-0.98)
Rescue PCI 1.76 0.223 5.82(0.343-98.57)
Pre-infarction angina 0.902 0.06 2.46(0.99-4.29)
Maximal inflation pressure of stent 0.335 0.009* 1.39(1.09-1.79)
Use of GP 2b3a inhibitor 5.67 <0.001* 29.98(20-44.89)
Syntax score 0.357 <0.001* 1.43(1.24-1.65)
Multivessel disease 1.56 0.002* 4.78(1.78-12.79)
CHA2DS2-VASc Risk Criteria 0.722 <0.001* 2.05(1.51-2.81
Pre-ballon dilatation with stenting 0.835 0.037* 2.30(1.05-5.05)
Post-ballon dilatation 1.426 0.006* 4.16(1.49-11.56)
Overall percent predicted=88.0%
Predictors for no reflow among studied cases.
56. In the present study; clinical, angiographic and laboratory predictive factors have
been recognized and correlated with presence of no reflow phenomenon with overall
percent predicted=88.0%.
Currently there are many lines to manage no reflow. Such patients warrant urgent
supportive measures to save life. Many lines of treatment are available depending
upon the underlying mechanism/s and the choice of interventional cardiologist.
Unfortunately, no reflow may prove resistant to pharmacological therapy in 5–10%
cases with adverse short term and long-term outcomes. A personalized attention to
tide over the crisis in cath lab is required for patient to prevent and promptly treat the
no-reflow phenomenon.
57. • Based on the present study, there are clinical, angiographic and laboratory
predictive factors associated with presence of no reflow phenomenon with
overall percent predicted=88.0%.
• Prevention is always better than treatment and no-reflow phenomenon should
be predicted and successfully treated to improve myocardial salvage and
improve outcomes.
58. • Angiographic examinations were performed by different clinicians and it is likely
that studies were performed with different sized catheters and angiographic
projections.
• In our study, we didn’t use ivus to identify atherosclerotic changes of coronaries.
• We have not analysed the microvascular function and no-reflow using myocardial
contrast echocardiography ,CMR or nuclear scintigraphy.
• A relatively small sample size, additional analysis of clinical, laboratory,
angiographic predictors of no-reflow phenomenon may be considered by
examing more cases.
59.
60. 432
: 26-01-2020
: 56 years old
Smoker, HTN
Typical anginal pain (CCS III)
: Lateral STEMI
61. : Standard Right Radial approach using XB3.5.
(LCX): Atherosclerotic Vessel showing
proximal subtotal atheroma 80 % stenosis with good distal flow.
: XB 3.5
PT 2 LS wire
NC TREK (4.00*15mm)
Resolute Integrity (4.00*18mm)
62.
63. 352
: 20-7-2019
: 55 years old
HTN,DM
Dyspnea and retrosternal chest pain (stuttering
course) during the previous week, becoming persistent and of
increased intensity on the morning of july 20 2019.
: Anterior STEMI
64. : Standard Right femoral approach using XB4.
LAD: atherosclerotic, sub- totally occluded at
its mid segment.
: XB 4
ASAHI soft floppy wire
NC Sprinter (3.50x15mm), NC Sprinter (3.75x21mm)
PROMUS (3.00*28mm)
65.
66. 351
: 19-7-2019
: 60 years old
HTN,DM,smoker
Acute severe burning retrosternal chest pain
Patient sought medical advice.
67. : Standard Right femoral approach using XB4.
LAD: Atherosclerotic Vessel showing
proximal and distal stenosis
: XB 4
PT 2 MS wire
Promus (3*38mm), Promus (2.5*38mm)
68.
69. 407
: 01-11-2019
: 64 years old
HTN,DM,smoker and upon solicitation of a more detailed
history, it became apparent that his father had suffered from an acute
myocardial infarction at the age of 50.
He describes the pain as a substernal heavy pressure
that radiates to his left arm, associated with diaphoresis, nausea, and
tingling in his fingers. His pain was minimally relieved with sublingual
nitroglycerin tablets.
70. : Standard Right radial approach using JL,JR 3.5.
LAD: Atherosclerotic Vessel with proximal to
midsegment subtotal significant lesion .
: XB3.5
ASAHI soft .
Resolute 2.5*22- 3*38
: PTCA 2*15
71.
72. 438
: 02-17-2020
: 65 years old
HTN
Acute typical chest pain from 4hours
before admission. she felt dyspnea and diaphoretic
• Patient sought medical advice .
73. : Standard Right femoral approach using JR 3.5.
LAD
• : XB 3.5
PT 2 LS.
Resolute (2.75*30 mm) and others
: MiniTREK (2*12) and others
Editor's Notes
Timely PPCI remain reperfusion strategy of choice for acute STEMI
NR is a common complication affecting prognosis And no operator didn’t face NR , thus prediction help prevention and treatment
Epicardial coronary artery opening with poor distal run off In absence of