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1. No-reflow can be diagnosed when dissection is present at the treatment site:

a. True
b. False

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Answer:  No-reflow is defined angiographically as an acute reduction in coronary flow (TIMI grade 0-1) in the absence of dissection, thrombus, spasm, or high-grade residual stenosis at the original target lesion. (Answer: b)

2. Risk factors for no-reflow include all of the following except:

a. Thrombus-containing lesions
b. Angulated lesions
c. Degenerated vein grafts
d. Rotablator atherectomy
e. Acute MI

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Answer:  No-reflow is more common after mechanical revascularization of thrombus-containing lesions (i.e., acute MI) and degenerated vein grafts containing friable debris. Among new devices, no-reflow is highest after Rotablator atherectomy (1.2-9.0%), correlates with total burr activation time, and is reversible in > 60% of episodes; the frequent response to intracoronary calcium antagonists is strongly suggestive of microvascular spasm. There is no relationship between no-reflow and angulated stenoses. (Answer: b)

3. No-reflow does not usually cause ECG changes or symptoms:

a. True
b. False

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Answer:  In the catheterization laboratory, no-reflow usually manifests as ECG changes and chest pain. However, depending on the myocardial territory, baseline ventricular function, and the presence of other coronary artery disease, no-reflow may be clinically silent, or induce a spectrum of ischemic manifestations including conduction disturbances, hypotension, myocardial infarction, cardiogenic shock, and death. (Answer: b)

4. No-reflow increases the risk of death and myocardial infarction after percutaneous revascularization:

a. True
b. False

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Answer:  In one study, no-reflow was associated with a 10-fold higher incidence of death (15%) and myocardial infarction (31%) compared to patients without no-reflow (even after excluding patients who presented with acute MI). (Answer: a)

5. Techniques to minimize the risk of no-reflow after Rotablator atherectomy of calcified lesions include all of the following except:

a. Small initial burr
b. Large single burr
c. Reduction in platform speed by < 5000 rpm
d. Ablation runs < 30 seconds            
e. Rotaflush cocktail (heparin, nitroglycerin, verapamil)

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Answer:  In heavily calcified lesions, Rotablator ablation may liberate large amounts of microparticles leading to no-reflow. Techniques to minimize complications include initial use of a 1.5 mm burr; further incremental steps in burr size of 0.25-0.5 mm; ablation runs < 30 seconds; and extended (occasionally several minutes) intervals between runs until hemodynamic dysfunction, ECG changes, and symptoms resolve. A fall in platform speed > 5000 RPM increases the risk of microparticulate embolization and no-reflow. A Rotoflush cocktail of heparin, vasodilators, and calcium antagonists is also useful for preventing no-reflow. (Answer: b)

6. Potentially useful therapies for no-reflow include:

a. Intracoronary calcium channel blockers
b. Intracoronary nitrates
c. Coronary artery bypass surgery

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Answer: The most important treatment of no-reflow is the use of intracoronary calcium antagonists. Intracoronary nitrates are much less effective, but may reverse superimposed spasm and are routinely administered. There are no data to support the use of beta-blockers, and since obstruction to coronary flow occurs at the level of the capillary, CABG is not beneficial. (Answer: all)

7. No-reflow resulting in hypotension is a contraindication to intracoronary calcium channel blockers:

a. True
b. False

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Answer:  Hypotension caused by no-reflow is not a contraindication to intracoronary calcium blockers — adjunctive therapy with pressures, inotropes, and IABP should be used as needed to support the systemic circulation while the calcium blocker is administered. (Answer: b)