The ClinicianThe ClinicianКлиницист1818-83382412-8775Publishing House ABV Press47010.17650/1818-8338-2021-15-1-4-K645EDITORIALРЕДАКЦИОННАЯ СТАТЬЯNo-reflow phenomenon and reperfusion injury. Mechanisms and treatmentФеномен no-reflow и реперфузионное повреждение миокарда: механизмы и методы леченияhttps://orcid.org/0000-0002-2870-3301GilyarovM. Yu.ГиляровМ. Ю.
Russian Federation

8 Leninskiy Avenue, Moscow 117049, Russia

1 Ostrovitianov St., Moscow 117997, Russia

Россия, 117049 Москва, Ленинский пр-кт, 8

Россия, 117997 Москва, ул. Островитянова, 1

https://orcid.org/0000-0003-3438-069XIvanovI. I.ИвановИ. И.
Russian Federation

1 Ostrovitianov St., Moscow 117997, Russia

Россия, 117997 Москва, ул. Островитянова, 1

https://orcid.org/0000-0003-4918-3795KonstantinovaE. V.КонстантиноваЕ. В.
Russian Federation

Ekaterina Vladimirovna Konstantinova

8 Leninskiy Avenue, Moscow 117049, Russia

1 Ostrovitianov St., Moscow 117997, Russia

Екатерина Владимировна Константинова

Россия, 117049 Москва, Ленинский пр-кт, 8

Россия, 117997 Москва, ул. Островитянова, 1

katekons@mail.ruhttps://orcid.org/0000-0002-0268-6961RaschetnovaN. I.РасчётноваН. И.
Russian Federation

1 Ostrovitianov St., Moscow 117997, Russia

Россия, 117997 Москва, ул. Островитянова, 1

https://orcid.org/0000-0003-4669-1006ShostakN. A.ШостакН. А.
Russian Federation

1 Ostrovitianov St., Moscow 117997, Russia

Россия, 117997 Москва, ул. Островитянова, 1

N.I. Pirogov City Clinical Hospital № 1, Moscow Healthcare DepartmentГБУЗ «Государственная клиническая больница № 1 им. Н. И. Пирогова Департамента здравоохранения г. Москвы»N.I. Pirogov Russian National Research Medical UniversityФГАОУ ВО «Российский национальный исследовательский медицинский университет им. Н. И. Пирогова» Минздрава России15102021151-410190503202205032022Copyright ©; 2021, Gilyarov M.Y., Ivanov I.I., Konstantinova E.V., Raschetnova N.I., Shostak N.A.Copyright ©; 2021, Гиляров М.Ю., Иванов И.И., Константинова Е.В., Расчётнова Н.И., Шостак Н.А.2021Gilyarov M.Y., Ivanov I.I., Konstantinova E.V., Raschetnova N.I., Shostak N.A.Гиляров М.Ю., Иванов И.И., Константинова Е.В., Расчётнова Н.И., Шостак Н.А.https://creativecommons.org/licenses/by/4.0https://klinitsist.abvpress.ru/Klin/article/view/470

Currently, one of the key methods of treating a patient with ST-elevation myocardial infarction is to restore blood flow to the infarct-related artery as quickly, completely and steadily as possible. However, in some cases, it is not possible to achieve adequate myocardial reperfusion, despite the restoration of coronary blood flow. This phenomenon was named no-reflow. Due to the lack of a unified approach to the diagnosis of no-reflow, its occurrence varies widely – from 2 to 44 %. Failure to achieve adequate myocardial perfusion leads to a higher mortality rate – from 7.4 to 30.3 %, as well as to more aggressive remodeling of the myocardium. For a long time, distal embolization in percutaneous coronary intervention was considered one of the leading mechanisms. However, the routine use of protective devices did not show a pronounced effect on the outcome and prognosis, although it is justified in certain clinical situations. Ischemic injury directly plays a significant role due to overload of cardiomyocytes with calcium, cellular edema, necrosis and apoptosis, which is significantly aggravated by myocardial reperfusion and forms obstruction at the level of the microcirculatory bed. More data is being accumulated about immune-mediated injury through activation of cellular immunity, intense inflammation and thrombosis in situ. Despite the success in the animal experiment, the clinical use of certain groups of drugs showed an ambiguous results. According to the latest recommendations European Society of Cardiology / European Association for Cardio-Thoracic Surgery (ESC / EACTS) 2018, GPIIb / IIIa platelet receptor inhibitors are recommended in the case of no-reflow. Besides this, according to the literature nicorandil and sodium nitroprusside, as well as IL-1β antagonists, seem to be promising. As a non-drug therapy, selective intracoronary hypothermia also has shown its effectiveness and safety in a pilot study. To date, it is clear that the no-reflow phenomenon is a manifestation of a complex cascade of reactions, including ischemic, reperfusion and immune-related injury, as well as distal embolization. Considering its significant contribution to the frequency of adverse outcomes and late complications, it seems necessary to introduce unified approaches to the diagnosis, prevention and treatment of no-reflow, which requires high-quality clinical studies.

В настоящее время одним из ключевых методов лечения пациентов с инфарктом миокарда с подъемом сегмента ST является как можно более быстрое, полное и устойчивое восстановление кровотока в инфарктсвязанной артерии. Однако в ряде случаев добиться адекватной реперфузии миокарда не удается, несмотря на восстановление коронарного кровотока. Данный феномен получил название “no-reflow”, или «синдром невосстановленного коронарного кровотока». В связи с отсутствием единого подхода к диагностике no-reflow его встречаемость варьируется в широких пределах – от 2 до 44 %. Недостижение адекватной перфузии миокарда приводит к более высокой летальности – от 7,4 до 30,3 %, а также к более агрессивному ремоделированию миокарда. Длительное время одним из ведущих механизмов считалась дистальная эмболия при чрескожном коронарном вмешательстве. Однако рутинное использование защитных устройств не показало выраженного влияния на исход и прогноз, хотя и является оправданным в отдельных клинических ситуациях. Существенную роль играет непосредственно ишемическое повреждение за счет перегрузки кардиомиоцитов ионами кальция, клеточного отека, некроза и апоптоза, что значительно усугубляется при реперфузии миокарда и формирует обструкцию на уровне микроциркуляторного русла. Все больше данных накапливается об иммуноопосредованном повреждении посредством активации клеточного иммунитета, интенсивного воспаления и тромбоза in situ. Несмотря на успехи экспериментов на животных, клиническое применение отдельных групп препаратов показало неоднозначный результат. Согласно последним рекомендациям Европейского общества кардиологов и Европейской ассоциации кардиоторакальных хирургов (European Society of Cardiology / European Association for Cardio-Thoracic Surgery, ESC / EACTS) от 2018 г. в случае no-reflow рекомендовано использование ингибиторов GPIIb / IIIa-рецепторов тромбоцитов. Кроме того, согласно данным литературы перспективным кажется применение никорандила и нитропруссида натрия, а также антагонистов интерлейкина 1β. В качестве немедикаментозной терапии заслуживает внимания селективная интракоронарная гипотермия, показавшая свою эффективность и безопасность в пилотном исследовании. На сегодняшний день ясно, что феномен no-reflow является проявлением сложного каскада реакций, включающих ишемическое, реперфузионное и иммунное повреждение, а также дистальную эмболию. Учитывая его весомый вклад в частоту неблагоприятных исходов и поздних осложнений, кажется необходимым введение единого подхода к диагностике, профилактике и лечению, что требует проведения качественных клинических исследований.

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