Adenosine-Induced Coronary Steal Is Observed in Patients Presenting With ST-Segment-Elevation Myocardial Infarction

Muhammad Aetesam-Ur-Rahman, Adam J Brown, Catherine Jaworski, Joel P Giblett, Tian X Zhao, Denise M Braganza, Sarah C Clarke, Bobby S K Agrawal, Martin R Bennett, Nick E J West, Stephen P Hoole, Muhammad Aetesam-Ur-Rahman, Adam J Brown, Catherine Jaworski, Joel P Giblett, Tian X Zhao, Denise M Braganza, Sarah C Clarke, Bobby S K Agrawal, Martin R Bennett, Nick E J West, Stephen P Hoole

Abstract

Background Adenosine is used to treat no-reflow in the infarct-related artery (IRA) during ST-segment-elevation myocardial infarction intervention. However, the physiological effect of adenosine in the IRA is variable. Coronary steal-a reduction of blood flow to the distal coronary bed-can occur in response to adenosine and this is facilitated by collaterals. We investigated the effects of adenosine on coronary flow reserve (CFR) in patients presenting with ST-segment-elevation myocardial infarction to better understand the physiological mechanism underpinning the variable response to adenosine. Methods and Results Pressure-wire assessment of the IRA after percutaneous coronary intervention was performed in 93 patients presenting with ST-segment-elevation myocardial infarction to calculate index of microvascular resistance, CFR, and collateral flow index by pressure. Modified collateral Rentrop grade to the IRA was recorded, as was microvascular obstruction by cardiac magnetic resonance imaging. Coronary steal (CFR <0.9), no change in flow (CFR=0.9-1.1), and hyperemic flow (CFR >1.1) after adenosine occurred in 19 (20%), 15 (16%), and 59 (63%) patients, respectively. Patients with coronary steal had higher modified Rentrop score to the IRA (1 [0, 1.75] versus 0 [0, 1], P<0.001) and a higher collateral flow index by pressure (0.25±0.10 versus 0.15±0.10, P=0.004) than the hyperemic group. The coronary steal group also had significantly higher index of microvascular resistance (61.68 [28.13, 87.04] versus 23.93 [14.67, 37.00], P=0.006) and had more disease (stenosis >50%) in the donor arteries (52.63% versus 22.03%, P=0.02) than the hyperemic group. Conclusions Adenosine-induced coronary steal may be responsible for a reduction in coronary flow reserve in a proportion of patients presenting with ST-segment-elevation myocardial infarction. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03145194. URL: https://www.isrctn.com; Unique identifier: ISRCTN3176727.

Keywords: ST‐segment–elevation myocardial infarction; adenosine; collateral circulation; microvascular dysfunction.

Conflict of interest statement

At the time of study, authors had no conflicts of interest to declare. West has been appointed as CMO of Abbott Vascular since completion of this study.

Figures

Figure 1. Schematic representation of coronary steal…
Figure 1. Schematic representation of coronary steal post‐PCI in patients presenting with STEMI.
Fixed microvascular injury (“closed,” nonresponding microvasculature) in the stented infarct‐related artery (IRA) territory fails to respond to adenosine, whereas the non‐IRA‐related artery microcirculation retains the ability to vasodilate. An upstream stenosis in the donor artery will result in a pressure gradient favoring collateral‐dependent coronary steal—a fall in collateral flow during arteriolar vasodilatation to less than resting baseline levels. Quantification and direction of coronary flow is graphically depicted by size and darkness of arrow. CAD indicates coronary artery disease; PCI, percutaneous coronary intervention; and STEMI, ST‐segment–elevation myocardial infarction.
Figure 2. Stratification of patients by coronary…
Figure 2. Stratification of patients by coronary flow reserve (CFR) derived by thermodilution transit time (Tmn).
A and B, Hyperemic adenosine response, CFR >1.1, n=59; (C and D) No effect of adenosine, CFR=0.9 to 1.10, n=15; (E and F) Coronary steal after adenosine, CFR <0.90, n=19. Data are given as mean±SD, with P<0.05 given as bold.
Figure 3. Recruitment details of study patients.
Figure 3. Recruitment details of study patients.
CMR indicates cardiac magnetic resonance; IMR, index of microcirculatory resistance; IRA, infarct‐related artery; MI, myocardial infarction; PPCI, primary percutaneous coronary intervention; and STEMI, ST‐segment–elevation myocardial infarction.
Figure 4. Receiver operator curves of the…
Figure 4. Receiver operator curves of the parameters (alone and in combination) associated with slow flow response to adenosine and coronary steal.
AUC indicates area under the curve; CFIp, collateral flow index by pressure; and IMR, index of microcirculatory resistance.

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