No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score

Luke P Dawson; Muhammad Rashid; Diem T Dinh; Angela Brennan; Jason E Bloom; Sinjini Biswas; Jeffrey Lefkovits; James A Shaw; William Chan; David J Clark; Ernesto Oqueli; Chin Hiew; Melanie Freeman; Andrew J Taylor; Christopher M Reid; Andrew E Ajani; David M Kaye; Mamas A Mamas; Dion Stub; MIG and BCIS Investigators

doi:10.1161/CIRCINTERVENTIONS.123.013738

No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score

Circ Cardiovasc Interv. 2024 Apr;17(4):e013738. doi: 10.1161/CIRCINTERVENTIONS.123.013738. Epub 2024 Mar 15.

Authors

Luke P Dawson^#^{1

2

3}, Muhammad Rashid^#^{4

5

6}, Diem T Dinh¹, Angela Brennan¹, Jason E Bloom^{2

3}, Sinjini Biswas¹, Jeffrey Lefkovits^{1

7}, James A Shaw^{2

3}, William Chan^{1

8}, David J Clark⁹, Ernesto Oqueli^{10

11}, Chin Hiew¹², Melanie Freeman¹³, Andrew J Taylor², Christopher M Reid^{1

14}, Andrew E Ajani^{1

4

5

6}, David M Kaye^{2

3}, Mamas A Mamas⁴, Dion Stub^{1

2

3}; MIG and BCIS Investigators

Affiliations

¹ Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.).
² Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.).
³ The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.).
⁴ Keele Cardiovascular Research Group, Centre for Prognosis Research, Stroke on Trent, United Kingdom (M.R., A.E.A., M.A.M.).
⁵ Department of Cardiovascular Sciences, National Institute for Health and Care Research (NIHR) Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester, United Kingdom (M.R., A.E.A.).
⁶ University Hospitals of Leicester National Health Service (NHS) Trust, United Kingdom (M.R., A.E.A.).
⁷ Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia (J.L.).
⁸ Department of Medicine, Melbourne University, Victoria, Australia (W.C.).
⁹ Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (D.J.C.).
¹⁰ Department of Cardiology, Grampians Health Ballarat, Victoria, Australia (E.O.).
¹¹ School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia (E.O.).
¹² Department of Cardiology, University Hospital Geelong, Victoria, Australia (C.H.).
¹³ Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia (M.F.).
¹⁴ Centre of Clinical Research and Education, School of Public Health, Curtin University, Perth, Western Australia, Australia (C.M.R.).

^# Contributed equally.

PMID: 38487882
DOI: 10.1161/CIRCINTERVENTIONS.123.013738

Abstract

Background: Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI.

Methods: We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005-2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006-2020; external validation cohort).

Results: A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment-elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively.

Conclusions: The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials.

Keywords: acute coronary syndrome; percutaneous coronary intervention; risk factors; risk score; stents.

MeSH terms

Acute Coronary Syndrome* / diagnostic imaging
Acute Coronary Syndrome* / therapy
Adult
Aged
Coronary Angiography
Female
Humans
Male
Middle Aged
Myocardial Infarction* / etiology
No-Reflow Phenomenon* / diagnostic imaging
No-Reflow Phenomenon* / etiology
Percutaneous Coronary Intervention* / adverse effects
Risk Factors
ST Elevation Myocardial Infarction* / diagnostic imaging
ST Elevation Myocardial Infarction* / etiology
ST Elevation Myocardial Infarction* / therapy
Treatment Outcome