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Original Article Acute Effects of Intracoronary Nicorandil and Nitroglycerin in Patients with Coronary Slow Flow

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Original Article Acute Effects of Intracoronary Nicorandil and Nitroglycerin in Patients with Coronary Slow Flow Int J Clin Exp Med 2016;9(6):11852-11858 www.ijcem.com /ISSN:1940-5901/IJCEM0022210 Original Article Acute effects of intracoronary nicorandil and nitroglycerin in patients with coronary slow flow Quanfang Zhang1, Zebo Xiu2, Wei Wang3, Zuoyuan Chen1, Zehua Dong4, Rongsun Zhang5 Departments of 1Cardiology, 3Pharmacy, 4ICU, 5Traditional Chinese Medicine, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong, China; 2Department of Cardiology, Liaocheng People’s Hospital and Lia- ocheng Clinical School of Taishan Medical College, Liaocheng 252000, Shangdong Province, China Received December 18, 2015; Accepted March 5, 2016; Epub June 15, 2016; Published June 30, 2016 Abstract: Objective: This study aimed to assess the acute effects of intracoronary nicorandil and nitroglycerin in pa- tients with coronary slow flow (CSF). Methods: Totally, 60 patients with CSF were enrolled in this retrospective study and divided into nicorandil group (n = 30) and nitroglycerin group (n = 30). Coronary angiography was administered to intracoronary nitroglycerin or nicorandil 30 seconds later. The coronary blood flow of patients was evaluated by thrombolysis in myocardial infarction (TIMI) frame count (TFC) method. Heart rate, systolic and diastolic blood pressures, and TFCs in left anterior descending artery (LAD), left circumflex artery (LCX), and right coronary artery (RCA) were recorded before and after administration with nicorandil or nitroglycerin. Results: After nitroglycerin administration, systolic and diastolic blood pressures decreased, heart rates significantly increased (P < 0.001). However, systolic and diastolic blood pressures, heart rate had no significant changes after the application of in- tracoronary nicorandil. In addition, after administration with nicorandil or nitroglycerin, TFCs in LAD, LCX, and RCA were significantly decreased (P < 0.001) compared with before administration; however, TFCs recovered to the normal level in the nicorandil group but not nitroglycerin group. We also found that the percentages reduction of TFCs in all coronaries were higher in the nicorandil group than that in the nitroglycerin group (P < 0.001). Coronary angiogram further showed that both nicorandil and nitroglycerin improved the coronary flow, while nicorandil had better improvement effect than nitroglycerin. Conclusions: The acute effect of intracoronary nicorandil is superior to nitroglycerin in ameliorating CSF. Keywords: Coronary slow flow, intracoronary nicorandil/nitroglycerin, thrombolysis in myocardial infarction frame count, coronary angiogra Introduction tion, microangiopathy, inflammation, athero- sclerosis, platelet dysfunction, and microvascu- The phenomenon of coronary slow flow (CSF) is lar spasm [5-7]. Hereinto, microangiopathy is not a rare angiographic finding, characterized considered as the most important reason for by delayed progression of contrast medium into the formation of CSF [8]. Therefore, some clini- distal coronary artery without obvious obstruc- cal drugs, which used to improve microvascular tive lesion stenosis in epicardial coronary artery function, are often applied in the treatment of [1, 2]. The patients with CSF are usually associ- CSF. Previous study has shown that intracoro- ated with clinical manifestations of a long peri- nary administration of nitroglycerin may not be od of chest pain or acute coronary syndrome effective to normalize the flow, especially such as arrhythmias, myocardial ischemia, sud- in patients with CSF who have angina symptom den cardiac death [3, 4]. However, little atten- [9, 10]. Exhilaratingly, nicorandil, a potassium tion has been focused on the CSF and the channel opener, is a novel anti-angina medica- pathophysiological mechanism of this phenom- tion and has a significant vasodilatory effect on enon is still unclear. small and large coronary arteries [11], which prompts that nicorandil may be a choice for the Currently, several studies have proposed that treatment of patients with CSF. Recently, Sani CSF may be related to endothelial cell dysfunc- et al. [12] have compared the efficacies of oral Effect of nicorandil and nitroglycerin on CSF nicorandil versus nitroglycerin for alleviating Study design angina in patients with CSF. However, few stud- ies have compared the acute effects of nicor- Totally, 60 eligible patients with CSF were divid- andil and nitroglycerin on the coronary flow ed into two groups according to the therapeutic improvement in patients with CSF. Therefore, medication: nicorandil group (n = 30, 22 males the present study compared the effects of the and 8 females, average age of 59.3 ± 11.5 intracoronary administration of nicorandil ver- years) and nitroglycerin group (n = 30, 19 males sus nitroglycerin during coronary angiography and 11 females, average age of 56.7 ± 11.2 on blood pressure, heart rate and thrombolysis years). The baseline characteristics, including in myocardial infarction (TIMI) frame counts age, sex, diabetes, hypertension, blood lipid, (TFC) in patients with CSF. body mass index (BMI), and adjuvant drugs were recorded. In addition, treadmill exercise Materials and methods testing (TET) was performed. Patients Treatment method Between November 2013 and December 2014, Selective coronary angiography was carried out a total of 4,300 patients with suspicious myo- using Allura Xper FD20 (Philips, Amsterdam, cardial ischemia performed coronary angiogra- Netherlands) by Judkins’ technique. Patients phy at the affiliated hospital of Qingdao univer- laid in the horizontal supine position and sity. The patients who diagnosed with CSF dur- accepted regional anesthesia. Next, patients ing angiography were included in this retro- performed radial artery or femoral artery punc- spective study. The CSF was diagnosed accord- ture, then the 6F angiography catheter was ing to TFCs method described by Gibson et al. placed into the aortic root via puncture site. [13]. Briefly, using an acquisition speed of 30 Contrast media was injected when catheter frames per second, the number of frames was was adjusted into left or right coronary open- calculated from the first frame to the last frame. ing. Meanwhile, continuous X-ray photography The first frame was confirmed when contrast was carried out at the appropriate section. media filled the origin of coronary artery, During angiography, patients with CSF in the touched both sides of the vessel wall, and nicorandil group were administrated with nicor- moved in an anterograde manner. The last andil (Sihuan Kebao pharmaceutical Co., LTD, frame was identified when contrast media Beijing, China) via coronary into the left (150 arrived at the distal landmark branch of coro- µg) or right (100 µg) coronary artery by a bolus- nary artery. Due to the greater length of left like injection. Nitroglycerin (Sihuan Kebao phar- anterior descending artery (LAD) than left cir- maceutical Co., LTD, Beijing, China) was admin- cumflex artery (LCX) and right coronary artery istered via coronary to the left (1.5 mg) or right (RCA), the frame count of LAD should be divid- (1 mg) coronary artery for the patients in the ed by 1.7 to obtain the corrected TFC (CTFC). nitroglycerin group. The CSF was defined as a CTFC > 27 in at least one vessel [14]. The exclusion criteria were: (1) Assessment during coronary angiography, no-reflow phe- nomenon, arterial narrowing > 50%, coronary Blood pressure and heart rate were recorded artery dilatation, or coronary artery spasm were before and after treatment for 30 seconds. In observed in patients; (2) patients had histories addition, the distribution and the number of of myocardial infarction and coronary artery artery with CSF were calculated. TFC of each intervention; (3) patients had cardiomyopathy, branch of coronary artery or CTFC were record- heart valve disease, hypertensive heart dis- ed pre- and post-administration. The percent- ease, connective tissue diseases, congenital age reduction of TFCs was measured as (TFC heart disease, or left ventricular ejection frac- before administration - TFC after administration)/TFC before treatment tion < 50%; and (4) patients were vulnerable to × 100%. nitroglycerin and nicorandil. As a result, a total of 60 patients with CSF were enrolled in our Statistical analysis study. Approval from the Ethics Committee of the affiliated hospital of Qingdao university was Data analysis was performed by using SPSS obtained. 15.0 software (SPSS Inc., Chicago, IL, USA). 11853 Int J Clin Exp Med 2016;9(6):11852-11858 Effect of nicorandil and nitroglycerin on CSF Table 1. Baseline characteristics of the patients in the nitroglycerin were found between the and nicorandil groups nicorandil and nitroglycerin Nitroglycerin group Nicorandil group groups in baseline character- Index P (n = 30) (n = 30) istics, including age, sex, dia- betes, hypertension, blood Age (year) 58.7 ± 10.6 59.3 ± 11.5 0.825 lipid and BMI, and adjuvant Male/female 21/9 22/8 0.774 drugs. In addition, there were Diabetes (%) 5 (16.7) 6 (20.0) 0.739 6 (20.0%) patients with posi- Hypertension (%) 17 (56.7) 19 (63.3) 0.598 tive TET in the nitroglycerin BMI (kg/m2) 27.3 ± 4.2 26.8 ± 4.0 0.635 group and 7 (23.3%) patients Adjuvant drugs (%) in the nicorandil group, with- β-blockers 9 (30.0) 11 (36.6) 0.584 out statistical difference. Statins 9 (30.0) 8 (26.7) 0.774 Coronary angiography dis- ARB 6 (13.3) 5 (16.7) 0.739 played that 60 patients had ACEI 7 (23.3) 9 (30.0) 0.559 no obvious stenosis in epicar- HDL-c (mmol/L) 1.3 ± 0.2 1.3 ± 0.3 0.695 dial coronary artery, while LDL-c
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