1. Coronary Slow Flow Phenomenon 冠状动脉慢血流现象 Hui YongMing Beijing Fengtai Hospital Medical Center of FengTai District Teaching Hospital of Capital Medical University

2. Coronary slow flow phenomenon (CSFP) is characterized by angiographically normal coronary arteries (no significant stenosis, spasm, dissection or thrombus) with delayed opacification of the distal vasculature. It was first described by Tambe et al. in 1972. Currently, although CSFP is a well known phenomenon by the invasive cardiologists, its etiology, pathophysiologic mechanisms, clinical manifestations and prognosis are not well known. Some studies show that CSFP may lead to angina pectoris and true myocardial infarction.

3. Overall, CSFP is observed in approximately 1% of the patients undergoing CAG. Mangieri et al. reported an incidence of 7% of this phenomenon in patients suspected to have cardiovascular disease; In our study, 4% incidence in CAG pats with suspected to have cardiovascular disease. 40 CSFP pats received long term follow- up study in our centre.

4. male ， 40 years Exertional chest distress 6 months,no chest pain, hospitalizing on Nov 15, 2007 EH 2 years; Smoking/drinking 20 years Chol 4.43 mmol/L (2.83-5.17) LDL 2.18 mmol/L (0-3.20) HDL 1.43 mmol/L (1.00-1.60) TG 5.43 mmol/L (0.56-1.71) UA 493 umol/L (140-420) UCG ： LV 45 ， LA 35 ， IVS 9 ， EF 60% Positive exercise testing ECG CASE1

6. CAG on Nov 23, 2007

7. Diagnosis ： CSFP Medicine ： ASP 100mg/day Control hypertension A calcium channel blocker ACEI Therapy of dyslipidemia Bad compliance for drug therapy

8. 2 months after leaving hospital Persisting Chest pain 22 Hr hospitalizing on Jan 29, 2008 ECG: Ⅰ、 avL ， V2-V5 ST↑0.1 ～ 0.5mV Myocardial enzyme :CK 1706 ， CK-MB 218

10. Diagnosis: ASTEMI Therapy : chest pain relaxed only conventional conservative therapy

11. CAG on the 3th day after AMI

12. Intensify anticoagulating and anti-platelet for one week ASP 300mg Qd Clopidogrel 75 mg Qd Tirofiban 0.1ug/kg/min 72h, Clexane 0.6ml ， IH ， Q12h Dipyridamole

14. CAG on 2 weeks after AMI

15. Follow up *I nterval ischemia symptom, especially afetr stopping anti- coagulating and anti-platelet therapy *ARR

16. male ， 47 years Exertional chest distress,no chest pain, EH 、 Smoking 、 Drinking Positive exercise testing Height 168CM, Weight 80Kg Chol 5.13 mmol/L (2.83-5.17) LDL 2.18 mmol/L (0-3.20) HDL 1.43 mmol/L (1.00-1.60) TG 7.43 mmol/L (0.56-1.71) UA 583 umol/L (140-420) CASE2

20. ASP 100mg Qd Clopidogrel 75 mg Qd Dipyridamole

21. Pathophysiological Mechanisms of CSFP Remain Uncertain Early phase of atherosclerosis Maybe relate to small vessel dysfunction (endothelial thicken, capillary damage, reduced small vessels diameter) imbalance between vasoconstrictor and vasodilatory factors Beltrame et al. report the presence of an increased resting coronary vasomotor tone in coronary resistance vessels in CSFP patients, and an improvement in coronary blood flow by using a calcium T-channel blocker in CSFP pats, suggesting the presence of microvascular spasm. platelet function disorder There has been evidence that inflammation plays an important role in development as well as evolution of atherosclerosis

22. Goel etal. have shown higher prevalence of positive exercise testing in CSFP patients compared with control subjects with normal coronary flow. Ersan Tatli documented the presence of myocardial ischemia using myocardial perfusion scintigraphy. Amasyali reported that CSFP may play a significant role in the pathogenesis of ventricular fibrillation of the patient. In our study, CSFP commonly in pats with middle-aged, smoker, untypical symptom, resting ECG change, positive exercise testing. So, CSFP is not purely an incidental angiographic finding; on the contrary, it may lead to angina pectoris and true myocardial ischemia, infarction. Some Clinical studies

23. Slow coronary flow phenomenon a kind of coronary disease ? slow coronary flow syndrome ? Classification and Prognosis

24. Pathophysiological mechanisms Epicardial Vessel or/and Microvessel Disorder Coronary slow flow phenomenon Clinical symptoms & events

25. Evaluation methods of Coronary Flow TIMI: Thrombolysis In Myocardial Infarction. Corrected TIMI Frame Count (CTFC) TMPG: TIMI myocardial perfusion grade. MBG: myocardial blush grade. Coronary Doppler Myocardial Contrast Echocardiography

26. Coronary Slow Flow: ＞ 2 SD frames

27. Corrected TIMI Frame Count(CTFC) CSFP was defined as a corrected TIMI frame count. 1) with a contrast infusion rate of 3.5 ml/s at 460 mbar 2) All the values initially published as “frame counts” referred to the video format standard in the United States, 30 frames / second. 3) The length of the LAD is 1.7 times greater than the LCX and the RCA. Thus, a correction factor was introduced in the TFC system when analyzing the LAD Normal Flow Value LAD 36±2.6  21±2.1 (after correct) LCX 22±4.1 RCA 20±3.0 average 21±3.1 Diagnosis of CSFP: Patients with a corrected TIMI frame count greater than 2 SD were considered as having CSFP.

28. 1 、 CSFP remains uncertain 2 、 Its etiology pathophysiologic mechanisms evaluation medthod therapy prognosis deserve further investigation. Conclusion

29. Control risk factors of coronary heart disease Therapy of dyslipidemia Nitrovasodilators: noneffective Dipyridamole, Persantin : effective A calcium channel blocker: limited Drug of improving endothelium function ( ACEI 、 Vitamin C 、 E) ?? Long-term Dual anti-platelet cohesion therapy Necessity ? ( if no contraindiction ) How long ? Conclusion- Therapy Strategy

30. Thanks !