Published online: 12.09.

2019
THIEME
Original Article 1

Predictors of Coronary Slow Flow Phenomenon:

A Retrospective Study
Satish Kumar Rao V.1  Indrani Garre1

1 Department of Cardiology, Nizam’s Institute of Medical Sciences, Address for correspondence  Satish Kumar Rao V., MD,
Hyderabad, Telangana, India DTCD, DM, Department of Cardiology, Nizam’s Institute of
Medical Sciences (NIMS), Hyderabad, Telangana 500082, India
(e-mail: [email protected]).

Ind J Car Dis Wom

Abstract Aim  This study aimed to analyze laboratory predictors, angiographic profile, clinical
profile, and risk factors for coronary slow flow (CSF) phenomenon without coronary
obstructive lesion in patients who came for a coronary angiogram.
Materials and Methods  The case-control study consisted of patients who u ­ nderwent
coronary angiography and were divided into two groups: patients with coronary
slow flow (case group, n = 100) and patients with the normal coronary flow (con-
trol group, n = 100). Coronary flow was studied using corrected thrombolysis in myo-
cardial infarction frame count (CTFC). The slow flow was defined as CTFC beyond 2
­standard deviations from the normal published range. Risk factors including age, sex,
diabetes mellitus (DM), hypertension, dyslipidemia, smoking, body mass index (BMI),
hematological and biochemical parameters (complete blood picture, platelet count,
total and differential leucocyte count, platelet-to-lymphocyte ratio [PLR], neutro-
phil-to-lymphocyte ratio [NLR] and lipid profile) were assessed. In both groups, clinical
information was collected, and laboratory parameters were measured and compared.
Results  Patients with CSF were more likely to be male and active smokers. Total
cholesterol, triglyceride, BMI, and DM were more commonly seen in the CSF group
compared with the control group. Inflammatory markers like uric acid (p = 0.03) and
high-sensitivity C-reactive protein (Hs-CRP) (p = 0.000) were found to be statistically
significant. Hematocrit (p = 0.023), NLR (p = 0.001), total cholesterol (p = 0.000), tri-
glycerides (p = 0.000), and BMI (p = 0.000) were statistically significant. PLR has the
tendency of statistically significance (p = 0.059). BMI, total cholesterol, triglycerides,
Keywords and Hs-CRP were strong predictors for CSF.
►►coronary angiogram Conclusion  CSF was common in males, smokers, DM patients, and it was associ-
►►slow flow ated with high NLR, uric acid, and Hs-CRP levels. The independent predictor of CSF
►►BMI was BMI, total cholesterol, triglycerides, and Hs-CRP levels. These findings provide an
►►DM impetus for additional studies to confirm the role of other inflammatory markers in
►►smoking CSF patients and treatment strategies depending on that.

Introduction artery stenosis. CSF phenomenon presents with various

manifestations like myocardial ischemia, life-threatening
Coronary slow flow (CSF) is a common finding in the coro- arrhythmias, sudden cardiac death, and recurrent acute
nary angiographic studies. CSF phenomenon is character- coronary syndromes (ACS). However, the etiopathogen-
ized by delayed coronary vessel opacification of the distal esis of CSF phenomenon remains only partially under-
segment in the absence of significant epicardial coronary stood. Endothelial dysfunction, subclinical atherosclerosis,

DOI https://doi.org/ ©2019 Women in Cardiology and

10.1055/s-0039-1696867 Related Sciences
2 Coronary Slow Flow Phenomenon  Rao V.

inflammation, ectasia, small vessel disease, and heart fail- 15 frames/second, and a correction factor of 1.7 for the left
ure are suggested as the various pathophysiological factors anterior descending (LAD) was taken for study.
of CSF
This study aims to correlate risk factors, clinical profile, Statistical Results
laboratory findings, and angiographic profile and find out Chi-square/Fisher’s exact test was studied to compare the
the common predictors in patients with CSF. statistical significance of categorical variables. Statistical
significance of the quantitative variables was analyzed with
unpaired Student’s t-test. The equality of variances between
Material and Methods
the two groups was studied by Leven’s test. Mann Whitney
The case-control study included patients who underwent U test was applied when quantitative variables did not fol-
coronary angiography between June 1, 2017, and May low a normal distribution. Multivariable logistic regression
31, 2018, in our institute were evaluated. A total of 100 was applied by using the enter method, and variables which
consecutive patients, cases with CSF phenomenon and 100 had a p-value of less than 0.05 by univariable methods were
controls with normal coronary (NC) flow were evaluated included. The statistical software Minitab 17 (Minitab, Ltd.,
in the p
­ resent study. United Kingdom) was used to analyze the data.

Cases: CSF Results

Inclusion Criteria This study consists of 100 cases (CSF) and 100 controls (NC)
Patients older than 18 years who present with chest pain which include 66% and 58% of males, 34% and 42% of females
or symptoms suggestive of angina equivalent with normal in case and control groups, respectively (►Table 1).
epicardial coronaries on coronary angiography but with the Mean age of case group is 54.97 ± 10.9 years and control
CSF in any of the coronary arteries are studied. group is 55.17 ± 10.8 years. Hypertension is present in 66% and
38%, DM in 67% and 37%, 46% and 14% are smokers, 43% and 19%
Exclusion Criteria are alcoholic, and dyslipidemia is present in 65% and 36% in case
Exclusion criteria included coronary artery disease (plaque, and control groups, respectively (►Tables 2 and 3 ; ►Figs. 1–5).
obstructive lesion), causes of secondary CSF phenomenon Various laboratory parameters like hematocrit, plate-
(spasm, ectasia), myocardial bridging, valvular disease, and let count, platelet-to-lymphocyte ratio (PLR) and neutro-
left ventricular systolic dysfunction. phil-to-lymphocyte ratio (NLR), uric acid, total cholesterol, tri-
glycerides, and Hs-CRP were assessed. Inflammatory markers
like uric acid (p = 0.03) and Hs-CRP (p = 0.000) were found
Control Group to be statistically significant. Hematocrit (p = 0.023), NLR
The control group (NC) comprised of 100 patients who (p = 0.001) total cholesterol (p = 0.000), triglycerides (p = 0.000),
underwent coronary angiography, which showed normal and BMI (p = 0.000) were statistically significant. PLR has the
epicardial coronary artery and normal flow. tendency of statistically significant (p = 0.059) (►Table 4).
Risk factors (age, sex, diabetes, hypertension, LAD (n = 50) is most frequently involved coronary artery
dyslipidemia, body mass index [BMI], and smoking), followed by left circumflex artery (LCX) (n = 16)) and
hematology and biochemical parameters like complete RCA (n = 34), and right dominant circulation noted in 89% in
blood picture, total platelet count, total and differen- case group (CSF) (►Table 5; ►Figs. 6 and 7).
tial leucocyte count, platelet-to-lymphocyte ratio (PLR) The most common presentation was chronic stable angina
and neutrophil-to-lymphocyte ratio (NLR), uric acid, lipid (CSA) in 56% and the remaining 44% with the acute coronary
profile, high-sensitivity C-reactive protein (Hs-CRP), and syndrome (ACS) (28% with the unstable angina [USA] and
HBA1C were assessed. In both groups, demographic and 16% with non-ST elevated myocardial infarction [NSTEMI]) in
clinical information was collected, and laboratory parame- patients with CSF (►Fig. 8).
ters were measured and compared.
Coronary blood flow was measured by using ­corrected Discussion
thrombolysis in myocardial infarction (TIMI) frame count
This study analyzed the laboratory predictors, risk factors,
(CTFC). The slow flow was defined as CTFC beyond 2
clinical presentation, and angiographic profile of patients
standard deviations (SDs) from normal published range.
associated with CSF phenomenon. In our study, BMI is a
strongly associated factor (p = 0.000) with CSF, which was also
Coronary Angiogram similar to other studies reported by authors.2-4 Yilmaz et al2 in
Coronary angiogram was performed using optitorque angio-
graphic catheters with manual injection. The angiograms
Table 1  Demographic data
for coronary flow measurement was studied using the CTFC
Variable Case (CSF) Control (NC)
method and the count value which exceeds 27, that is, great-
(n = 100) (n = 100)
er than 2 SDs from the normal published range of 21 ± 3
was noted as abnormal and suggestive of CSF ­phenomenon Male 66 58
as described by Gibson et al.1 Image frame count of Female 34 42

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 Coronary Slow Flow Phenomenon  Rao V. 3

Table 2  Risk factors among the study groups in males

Males Cases (CSF) n = 66 Control (NC) n = 58 p-Value
Hypertension 43 (65.1%) 22 (37.9%) 0.002
Diabetes mellitus 48 (72.7%) 27 (46.5%) 0.002
Smoking 45 (68.1%) 14 (24.1%) 0.000
Alcohol 42 (63.6%) 19 (32.7%) 0.000
Dyslipidemia 43 (65.1%) 23 (39.6%) 0.003

Table 3  Risk factors among the study groups in Females

Females Cases (CSF) n = 34 Control (NC) n = 42 p-Value
Hypertension 23 (67.4%) 16 (38.1%) 0.007
Diabetes mellitus 19 (55.9%) 10 (23.8%) 0.003
Smoking 01 (2.9%) 00 –
Alcohol 01 (2.9%) 00 –
Dyslipidemia 22 (67.6%) 13 (30.9%) 0.001

Fig. 1  Gender distribution between study groups.

Fig. 3  Age distribution in control (NC) group.

study population. A study in an Iranian population showed

Fig. 2  Age distribution in cases (CSF) group.
that diabetes and hypertension are independent risk factors
for CSF, which is similar to our study group. Because of mul-
a Turkish population study and Hawkins et al4 in the North tiple causative factors for slow flow, the evidence shows the
American population showed BMI to have an independent endothelial dysfunction, which causes small vessel disease is
association with CSF. In another study performed by Beltrame the main causative factor responsible for CSF phenomenon.
et al in an Australian population, males and smokers were In our study, the common clinical presentation was chron-
independent risk factors for CSF.5 A study in Chinese popu- ic stable angina (56%) and 44% with ACS (28% with USA),
lation showed that hyperglycemia, Hs-CRP, and increased and 16% with (NSTEMI in patients with CSF. Presentation
platelet count and uric acid which causes endothelial dys- is diverse from atypical chest pain, chronic stable angina or
function are the risk factors for CSF6 which is similar to our USA, NSTEMI to ST-elevation myocardial infarction (STEMI)

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4 Coronary Slow Flow Phenomenon  Rao V.

Fig. 4  Risk factors in cases (CSF) group.

Fig. 5  Risk factors in control (NC) group.

Table 4  Laboratory variables in case and control

Variable Case (CSF) Control (NC) P-Value
Hematocrit (%) 42.5 ± 3.17 41.5 ± 3.01 0.023
Platelet count (lakh/mm3) 2.06 ± 0.59 2.01 ± 0.69 0.582
PLR (%) 2.4 ± 1.3 2.1 ± 0.9 0.059
NLR (%) 3 ± 1.8 2.3 ± 1.2 0.001
Uric acid (µmol/L) 6.19 ± 1.73 5.7 ± 1.42 0.03
Hs-CRP (mg/L) 11.3 ± 1.6 6.5 ± 1.1 0.000
Total cholesterol (mg/dL) 216 ± 44.1 148.8 ± 18.8 0.000
Triglycerides (mg/dL) 206.1 ± 71.3 116.3 ± 16.1 0.000
BMI 32.4 ± 4.2 23 ± 1.5 0.000
Abbreviations: PLR, platelet-to-lymphocyte ratio; NLR, neutrophil-to-lymphocyte ratio; Hs-CRP, high-sensitivity C-reactive protein.

Table 5  Slow flow distribution in coronary vessels

Slow flow Dominance
LAD LCX RCA Right Left
Males 34 11 21 57 09
Females 16 05 13 32 02
Abbreviations: LAD, left anterior descending; LCX, left circumflex artery; RCA, right coronary artery.

Fig. 6  Slow flow distribution in coronary vessels (males).

Fig. 7  Slow flow distribution in coronary vessels (females).

as studies by Gökçe et al and Amirzadegan et al5,7-10 show. In
a study conducted in the Iranian population with CSF phe-
nomenon, 75% of the patients presented with ACS which nonspecific chest pain (71.9%) followed by ACS (18.4%) and
is different from our study where CSA is more common. chronic stable angina (8.8%) in a study conducted by Yaron et
The most common presentation of CSF phenomenon was al11 in an Israeli population. LAD artery is the most common

Indian Journal of Cardiovascular Disease in Women WINCARS

 Coronary Slow Flow Phenomenon  Rao V. 5

Fig. 8  Gender distribution of presentation between study groups.

coronary artery involved (n = 50), followed by LCX (n = 16) positive independent association between levels of serum
and right coronary artery (RCA) (n = 34) which is similar- uric acid and CSF phenomenon. In our study, we found that
ly reported in other study populations.8,10Pontiroli et al12 in serum uric acid levels were significantly higher in patients
his study population showed that a reduction in BMI after with CSF phenomenon when compared with the control
surgical procedures like gastric banding is associated with group. There is considerable evidence that CSF occurs as a
significant improvement in markers causing endothelial dys- result of coronary microvascular dysfunction, which is sec-
function, which is the causative factor for CSF phenomenon. ondary to endothelial dysfunction. It was noted that coronary
BMI is found to be the strongest predictor of coronary slow flow reserve (CFR), as an indicator of coronary microvascu-
flow (p = 0.000) in our study population. Newer studies need lar function, is impaired in patients with CSF phenomenon.20
to be conducted in the future to see whether a reduction in Reduced CFR is the earliest manifestation of coronary athero-
BMI decreases the markers of endothelial dysfunction, which sclerosis. Kanbay et al21 showed that uric acid has a role in
causes CSF phenomenon and improves the coronary flow. coronary microvascular disease and CFR. Uric acid by induc-
The endothelium plays a pivotal role by regulating coro- ing vascular smooth muscle cell proliferation and causing
nary vascular tone and control coronary blood flow.13 Mea- increased oxidative stress via the vascular renin-angiotensin
surement of endothelial function, by the brachial artery system causes coronary microvascular disease.22 Güllü et al23
flow-mediated dilatation (FMD), is impaired in people pre- have found that serum uric acid levels are inversely related
senting with CSF.14 In patients with CSF nitric oxide (NO) bio- with CFR which have a role in coronary microvascular disease
activity is decreased, and impaired vascular endothelial func- in healthy individuals. Cin et al24 investigated coronary artery
tion is seen.15 It is noted that the concentration of adiponectin morphology in patients with CSF phenomenon and found
and paraoxonase activity two critical markers of endothelial out that diffuse intimal thickening, atheroma, does not cause
dysfunction are markedly reduced in patients with a CSF.16 luminal irregularities and widespread calcification in the cor-
High levels of serum uric acid were found in patients with onary vessel wall, suggesting that the CSF phenomenon is a
endothelial dysfunction, which is a causative factor for CSF form of early-stage coronary atherosclerosis in their coronary
phenomenon.17 Uric acid is known to induce endotheli- angiographic analysis of patients with CSF. Consistent with
al dysfunction via down-regulating NO production and by our results, Naing et al recently found that uric acid was the
mitochondrial Na+/Ca2+ exchanger-mediated mitochondri- most important determining risk factor for CSF phenomenon.
al calcium overload.18 Besides, Elbasan et al19 in their study Inflammation has a vital role in the pathogenesis of CSF;
in cardiac syndrome X patients demonstrated a significant the association of CSF with inflammatory markers remains

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6 Coronary Slow Flow Phenomenon  Rao V.

controversial. Association of inflammation with CSF is not- 4 Hawkins BM, Stavrakis S, Rousan TA, Abu-Fadel M, Schechter
ed in various studies.25 NLR ratio provides an easy but also a E. Coronary slow flow—prevalence and clinical correlations.
Circ J 2012;76(4):936–942
promising method to screen for systemic inflammation, and
5 Beltrame JF, Limaye SB, Horowitz JD. The coronary slow flow
it is widely used as a marker for CSF cardiovascular diseases.26 phenomenon—a new coronary microvascular disorder. Cardi-
Elevated NLR and serum uric acid is indicative of a systemic ology 2002;97(4):197–202
inflammatory response and was found to be associated with 6 Xia S, Deng SB, Wang Y, et al. Clinical analysis of the risk factors
CSF27,28 and statistically significant (p = 0.001). In some stud- of slow coronary flow. Heart Vessels 2011;26(5):480–486
ies, elevated hemoglobin or hematocrit is noted in patients 7 Moazenzadeh M, Azimzadeh BS, Zare J, et al. Clinical features
and main determinants of coronary slow flow phenomenon in
with CSF,29,30 which does not have statistical significance as
Iranian patients. Eur J Cardiovasc Med 2010;1(2):2042–4884
noted in other studies.31,32 In our study, hematocrit was sta- 8 Gökçe M, Kaplan S, Tekelioğlu Y, Erdoğan T, Küçükosmanoğlu
tistically significant (p = 0.002); Cetin et al showed blood vis- M. Platelet function disorder in patients with coronary slow
cosity, which is based on hematocrit and total serum protein, flow. Clin Cardiol 2005;28(3):145–148
is an independent predictor of CSF.33 Endothelial dysfunction 9 Amirzadegan A, Motamed A, Davarpasand T, Shahrzad M,
is induced by increased blood viscosity in patients with CSF Lotfi-Tokaldany M. Clinical characteristics and mid-term
outcome of patients with slow coronary flow. Acta Cardiol
phenomenon. Platelet activation is precipitated by increased
2012;67(5):583–587
blood viscosity and shear stress in coronary arteries.34 In 10 Sanati H, Kiani R, Shakerian F, et al. Coronary slow flow phe-
recent studies, PLR is found to be higher in patients with nomenon: clinical findings and predictors. Res Cardiovasc
CSF.35,36 PLR is raised in CSF cases and has a tendency for being Med 2016;5(1):e30296
statistically significant (p = 0.059). 11 Arbel Y, Rind E, Banai S, et al. Prevalence and predictors of
slow flow in angiographically normal coronary arteries. Clin
Earlier studies have shown that endothelial dysfunction,
Hemorheol Microcirc 2012;52(1):5–14
subclinical atherosclerosis, inflammation, small vessel dis- 12 Pontiroli AE, Pizzocri P, Paroni R, Folli F. Sympathetic overac-
ease, and anatomy of coronary arteries are the causative fac- tivity, endothelial dysfunction, inflammation, and metabolic
tors for CSF phenomenon. The current findings showed that abnormalities cluster in grade III (World Health Organiza-
CSF is a part of systemic vascular disorder and inflammation. tion) obesity: reversal through sustained weight loss obtained
Further studies are needed to reveal the pathogenesis with laparoscopic adjustable gastric banding. Diabetes Care
2006;29(12):2735–2738
causing CSF. Large-scale clinical studies are necessary to
13 Lüscher TF, Richard V, Tschudi M, Yang ZH, Boulanger C. Endo-
characterize the CSF phenomenon better and investigate var- thelial control of vascular tone in large and small coronary
ious potential therapeutic approaches. arteries. J Am Coll Cardiol 1990;15(3):519–527
14 Damaske A, Muxel S, Fasola F, et al. Peripheral hemorheo-
Limitations logical and vascular correlates of coronary blood flow. Clin
The design of our study is descriptive and retrospective. A Hemorheol Microcirc 2011;49(1-4):261–269
15 Sezgin N, Barutcu I, Sezgin AT, et al. Plasma nitric oxide level
single-spot blood sample was taken, and the temporal trend
and its role in slow coronary flow phenomenon. Int Heart J
of changes during hospitalization was not known. 2005;46(3):373–382
16 Selcuk H, Selcuk MT, Temizhan A, et al. Decreased plasma
concentrations of adiponectin in patients with slow coronary
Conclusions flow. Heart Vessels 2009;24(1):1–7
17 Kanbay M, Segal M, Afsar B, Kang DH, Rodriguez-Iturbe B,
CSF was common in males, smokers, and DM patients and is
Johnson RJ. The role of uric acid in the pathogenesis of human
associated with high NLR, uric acid, and Hs-CRP levels. We
cardiovascular disease. Heart 2013;99(11):759–766
found BMI, Hs-CRP, total cholesterol, and triglycerides to have 18 Papežíková I, Pekarová M, Kolářová H, et al. Uric acid modulates
an independent risk factor associated with CSF phenomenon in vascular endothelial function through the down regulation of
our study. These findings provide an additional impetus for fur- nitric oxide production. Free Radic Res 2013;47(2):82–88
ther studies to confirm the role of other inflammatory markers 19 Elbasan Z, Sahin DY, Gür M, et al.Serum uric acid and slow cor-
onary flow in cardiac syndrome X. Herz 2013;38(5):544–548
in CSF patients and treatment strategies depending on that.
20 Erdogan D, Caliskan M, Gullu H, Sezgin AT, Yildirir A, Muder-
Conflict of Interest risoglu H. Coronary flow reserve is impaired in patients with
slow coronary flow. Atherosclerosis 2007;191(1):168–174
None. 
21 Kanbay M, Sánchez-Lozada LG, Franco M, et al. Microvascular
disease and its role in the brain and cardiovascular system: a
potential role for uric acid as a cardiorenal toxin. Nephrol Dial
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