- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT01747174
REperfusion Facilitated by LOcal Adjunctive Therapy in ST-elevation Myocardial Infarction (REFLO-STEMI)
Randomized Controlled Trial Comparing Intracoronary Administration of Adenosine or Sodium Nitroprusside to Control for Attenuation of Microvascular Obstruction During Primary Percutaneous Coronary Intervention
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
>100,000 patients suffering STEMI present in the UK each year. P-PCI in the UK is increasing exponentially. In 2004 there were <1500 P-PCI and in 2007 and 2008 these figures had increased to 5902 and 9224 respectively (BCIS database).
Although P-PCI delivered quickly is more effective than thrombolysis, the efficacy of this, essentially mechanical, technique is limited by the unpredictable phenomenon of no-reflow and the under-stated lesser degrees of MVO. As more UK centres adopt P-PCI the dilemma of how to attenuate MVO will remain. Currently there is no consensus on the optimal management to prevent or attenuate MVO particularly when thrombus laden lesions are treated with P-PCI.
There is divergent clinical practice, even within institutions, in the UK and worldwide. This is because there is no solid evidence base to inform clinicians. The current options for interventional cardiologists are:
- Routinely aspirate thrombus and give IC vasodilator during the intervention but only in high burden thrombus formation lesions.
- Perform a standard P-PCI only and then give IV vasodilator if angiographic no-reflow develops.
- Routinely consider that angiographically silent MVO (i.e a grade below true "no-reflow") may have important impact on infarct size and clinical outcome and treat prophylactically.
Few if any clinicians follow this thinking. Indeed, it appears impossible to predict the incidence of (no-reflow/MVO) from the presenting angiogram (pre- or post- wire or balloon) and it can be argued that irrespective of thrombus burden it would be better to undertake prophylactic treatment in all patients, following the use of aspiration catheter, with delivery of agents able, in theory at least, to reduce (angiographically undetectable) MVO. Several studies of IC adenosine or SNP have shown favourable effects in attenuating MVO. However, the size of effect with either drug and whether indeed there is a difference between them in reducing MVO and infarct size is undetermined.
The objectives of our proposed study are to determine:
- Whether adjunctive pharmaco-therapy at time of P-PCI and following thrombus aspiration, reduces CMR-determined MVO and infarct size.
- Whether there is a difference between adenosine and SNP in reducing CMR-detected MVO and infarct size, both given selectively and distally via a thrombus aspiration catheter or a coronary microcatheter.
- The correlation of angiographic, including the recently designed computer-assisted myocardial blush quantification 'Quantitative Blush Evaluator'(QuBE), and other myocardial perfusion markers, with CMR detected MVO and infarct size, as well as with clinical outcome (MACE) at 30 days.
Study Type
Enrollment (Actual)
Phase
- Phase 2
Contacts and Locations
Study Locations
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Leicestershire
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Leicester, Leicestershire, United Kingdom, LE3 9QP
- Glenfield Hospital
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Tyne and Wear
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Newcastle upon Tyne, Tyne and Wear, United Kingdom, NE7 7DN
- Freeman Hospital
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West Midlands
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Coventry, West Midlands, United Kingdom, CV2 2DX
- University Hospital
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West Yorkshire
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Leeds, West Yorkshire, United Kingdom, LS1 3EX
- Leeds General Infirmary
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- ≥ 18 years age.
- Informed ASSENT (verbal consent) prior to angiography.
- STEMI ≤ 6 hrs of symptom onset, requiring primary reperfusion by PCI.
- Single-vessel coronary artery disease (non culprit disease ≤70% stenosis at angiography)
- TIMI flow 0/I at angiography.
Exclusion Criteria:
- Contraindications to: P-PCI *, CMR**, contrast agents, or study medications: Adenosine***, SNP****, Aspirin, Thienopyridine and Bivalirudin.
- SBP ≤ 90mmHg
- Cardiogenic Shock
- Previous Q wave myocardial infarction
- Culprit lesion not identified or located in a by-pass graft
- Stent thrombosis.
- Left main disease.
- Known severe asthma.
- Known stage 4 or 5 chronic kidney disease (eGFR<30ml/min).
- Pregnancy.
Notes:
- * Exclusion criteria for P-PCI (presentation timing, inadequate arterial access etc); patient unable to tolerate "prolonged" PCI procedure (in operators' opinion).
- ** Absolute contra-indication to CMR (Pacemaker, ICD, intra-cranial metal clips).
- *** Contraindications to Adenosine (known hypersensitivity to Adenosine, sick sinus syndrome, second or third degree atrio-ventricular block - except in patients with functioning artificial pacemaker, long QT syndrome has been defined as QTc > 450 ms at baseline). ECG will be undertaken just after the first dose of the study drug and QT/QTc will be recorded and compared to the baseline. If the QTc recorded after the first dose of the study drug exceeds 450ms or there is an increase in the QT/QTc of > 60 ms from baseline, the second dose will be abandoned and this will be recorded.
- **** Contraindications to SNP (known hypersensitivity to SNP, compensatory hypertension - as may be seen in arteriovenous shunts or coarctation of the aorta, high output failure, congenital optic atrophy or tobacco amblyopia).
Study Plan
How is the study designed?
Design Details
- Primary Purpose: PREVENTION
- Allocation: RANDOMIZED
- Interventional Model: PARALLEL
- Masking: SINGLE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
EXPERIMENTAL: Std PCI + Intra-coronary (IC) Adenosine
IC Adenosine in to IRA (following thrombus aspiration) with further dose via guide catheter following coronary stent deployment.
|
IC Adenosine 1mg injected distally via micro-catheter in to IRA following thrombus aspiration with further dose (1mg if IRA is RCA otherwise 2mg) via guide catheter following coronary stent deployment.
Other Names:
PCI procedure with thrombectomy (via aspiration catheter) and bivalirudin given as standard.
|
EXPERIMENTAL: Std PCI + IC Sodium Nitroprusside (SNP)
IC SNP in to IRA (following thrombus aspiration) with further dose via guide catheter following coronary stent deployment.
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PCI procedure with thrombectomy (via aspiration catheter) and bivalirudin given as standard.
IC SNP 250mcg injected distally via micro-catheter distally in to IRA following thrombus aspiration with further 250 mcg dose delivered via guide catheter following coronary stent deployment.
Other Names:
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ACTIVE_COMPARATOR: Std PCI
Standard PCI only
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PCI procedure with thrombectomy (via aspiration catheter) and bivalirudin given as standard.
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Time Frame |
---|---|
CMR measured infarct size (% LV mass)
Time Frame: 48-72 hours post procedure
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48-72 hours post procedure
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
CMR incidence and extent of MVO (% LV mass)
Time Frame: 48-72 hours post procedure
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48-72 hours post procedure
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CMR measured myocardial salvage index, haemorrhage, LV EF and volumes
Time Frame: 48-72 hours post procedure
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48-72 hours post procedure
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Myocardial Blush Grade assessed by validated computer software 'Quantitative Blush Evaluator' (QuBE
Time Frame: During P-PCI
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During P-PCI
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Incidence pre- and post- procedure angiographic true "no-reflow"
Time Frame: During P-PCI
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During P-PCI
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Any in-patient clinical events
Time Frame: Within 6 months from presentation with, and PCI for, STEMI
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Includes: coronary artery re-occlusion, need for repeat PCI, recurrent chest pain with new ECG changes, incidence of clinical heart failure (symptoms plus basal crackles plus X-ray evidence of pulmonary congestion) and proven cerebrovascular accident (CVA).
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Within 6 months from presentation with, and PCI for, STEMI
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Overall MACE
Time Frame: 1 month
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MACE: composite of death, need for target lesion revascularization, recurrent MI, severe heart failure, and CVA.
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1 month
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Degree of ST segment resolution on ECG
Time Frame: Assessed immediately following P-PCI (expected on average 1 hour)
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Assessed immediately following P-PCI (expected on average 1 hour)
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Echocardiographic assessment of LV
Time Frame: 6-8 weeks post-procedure/MI
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To include end systolic/diastolic volumes, EF +/- wall motion index
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6-8 weeks post-procedure/MI
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Corrected TIMI Frame Count
Time Frame: During procedure
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TIMI frame count or TFC is defined as the number of cineframes required for contrast to reach a standardized distal coronary landmark in the culprit vessel.
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During procedure
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Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Anthony H Gershlick, MBBS, FRCP, University of Leicester
Publications and helpful links
General Publications
- Nazir SA, McCann GP, Greenwood JP, Kunadian V, Khan JN, Mahmoud IZ, Blackman DJ, Been M, Abrams KR, Shipley L, Wilcox R, Adgey AA, Gershlick AH. Strategies to attenuate micro-vascular obstruction during P-PCI: the randomized reperfusion facilitated by local adjunctive therapy in ST-elevation myocardial infarction trial. Eur Heart J. 2016 Jun 21;37(24):1910-9. doi: 10.1093/eurheartj/ehw136. Epub 2016 May 4.
- Nazir SA, Khan JN, Mahmoud IZ, Greenwood JP, Blackman DJ, Kunadian V, Been M, Abrams KR, Wilcox R, Adgey AA, McCann GP, Gershlick AH. The REFLO-STEMI trial comparing intracoronary adenosine, sodium nitroprusside and standard therapy for the attenuation of infarct size and microvascular obstruction during primary percutaneous coronary intervention: study protocol for a randomised controlled trial. Trials. 2014 Sep 25;15:371. doi: 10.1186/1745-6215-15-371.
Study record dates
Study Major Dates
Study Start
Primary Completion (ACTUAL)
Study Completion (ACTUAL)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ESTIMATE)
Study Record Updates
Last Update Posted (ESTIMATE)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Ischemia
- Pathologic Processes
- Necrosis
- Myocardial Ischemia
- Heart Diseases
- Cardiovascular Diseases
- Vascular Diseases
- Myocardial Infarction
- Infarction
- ST Elevation Myocardial Infarction
- Physiological Effects of Drugs
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Anti-Arrhythmia Agents
- Antihypertensive Agents
- Vasodilator Agents
- Peripheral Nervous System Agents
- Analgesics
- Sensory System Agents
- Purinergic Agents
- Purinergic P1 Receptor Agonists
- Purinergic Agonists
- Nitric Oxide Donors
- Adenosine
- Nitroprusside
Other Study ID Numbers
- CLRN 53469
- 2010-023211-34 (EUDRACT_NUMBER)
- 09/150/28 (OTHER_GRANT: NIHR EME)
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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