Thrombus Aspiration in STEMI Meta-Analysis

Study Questions:

What are the benefits and risks of thrombus aspiration during percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI)?

Methods:

Included were large (≥1,000) randomized controlled trials comparing manual thrombectomy versus PCI alone in patients with STEMI. Individual patient data were provided by the leadership of each trial. The prespecified primary efficacy outcome was cardiovascular (CV) mortality within 30 days, and the primary safety outcome was stroke or transient ischemic attack (TIA) within 30 days.

Results:

The three eligible randomized trials (TAPAS, TASTE, and TOTAL) enrolled 19,047 patients, of whom 18,306 underwent PCI and were included in the primary analysis. CV death at 30 days occurred in 221 (2.4%) of 9,155 patients randomized to thrombus aspiration, and 262 (2.9%) of 9,151 randomized to PCI alone (hazard ratio [HR], 0.84; 95% confidence interval [CI], 0.70-1.01; p = 0.06). Stroke or TIA occurred in 66 (0.8%) randomized to thrombus aspiration and 46 (0.5%) randomized to PCI alone (odds ratio [OR], 1.43; 95% CI, 0.98-2.1; p = 0.06). There were no significant differences in recurrent myocardial infarction, stent thrombosis, heart failure, or target vessel revascularization. In the subgroup with high thrombus burden (TIMI thrombus grade ≥3), thrombus aspiration was associated with less CV death (170 [2.5%] vs. 205 [3.1%]; HR, 0.80; 95% CI, 0.65-0.98; p = 0.03), and with more stroke or TIA (55 [0.9%] vs. 34 [0.5%]; OR, 1.56; 95% CI, 1.02-2.42; p = 0.04). However, the interaction p values were 0.32 and 0.34, respectively.

Conclusions:

The authors concluded that routine thrombus aspiration during STEMI PCI did not improve clinical outcomes.

Perspective:

This meta-analysis reports that consistent with large contemporary trials, routine manual thrombus aspiration during STEMI PCI did not improve clinical outcomes overall. Although there were no statistically significant subgroup interactions, in the subgroup of patients with high thrombus burden, there was a nominal reduction in CV mortality and in all-cause mortality, but an increase in stroke or TIA at 30 days. Whether improved methods for thrombus aspiration could reduce the risk of stroke and enhance overall benefit among patients with high thrombus burden cannot answered by this post hoc subgroup analysis, and would need a prospective randomized study.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS

Keywords: Acute Coronary Syndrome, Heart Failure, Ischemic Attack, Transient, Mortality, Myocardial Infarction, Myocardial Revascularization, Outcome Assessment (Health Care), Percutaneous Coronary Intervention, Risk Assessment, Stents, Stroke, Thrombectomy, Thrombosis


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