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Ischemic Time and Thrombus Aspiration in STEMI
Quick Takes
- Similar to results of the main TOTAL trial, thrombus aspiration did not result in improved clinical outcomes among patients with shorter ischemic times.
- Although there was evidence of less distal embolizaton among patients with shorter ischemic times who underwent thrombus aspiration, this did not translate into improved clinical outcomes.
Study Questions:
Does thrombus aspiration benefit patients presenting with ST-segment elevation myocardial infarction (STEMI) and shorter ischemic time?
Methods:
The TOTAL (Thrombectomy With PCI vs PCI Alone in Patients With STEMI) trial was an international randomized clinical trial of 10,732 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) within 12 hours of symptom onset. Patients were recruited between August 5, 2010, and July 25, 2014, and were followed up for 1 year. Data analysis was performed from February 22, 2019, to January 5, 2021.
Results:
The study randomized 10,732 patients, and 9,986 underwent primary PCI and had time data available (7,737 men [77.5%]; mean [SD] age, 61.0 [12.0] years). For the randomized comparison of thrombus aspiration, there was a reduction in angiographic distal embolization with thrombus aspiration that was more pronounced in patients with short ischemic times (6 hours: odds ratio, 0.70; 95% confidence interval [CI], 0.33-1.50; p = 0.12 for interaction). However, for the primary composite outcome, there was no benefit based on: 1) total ischemic time (6 hours: hazard ratio [HR], 0.87; 95% CI, 0.60-1.27; p = 0.46 for interaction), or 2) first medical contact (FMC)-to-device time (90-120 minutes: HR, 1.19 [95% CI, 0.85-1.67]; >120 minutes: HR, 0.89 [95% CI, 0.70-1.14]; p = 0.54 for interaction). In a multivariable analysis, both total ischemic time (>2 hours: HR, 1.26; 95% CI, 1.00-1.58) and FMC-to-device time (>120 minutes: HR, 1.45; 95% CI, 1.18-1.79) were independently associated with cardiovascular mortality.
Conclusions:
This analysis suggests that thrombus aspiration does not appear to be associated with an improvement in clinical outcomes regardless of ischemic time. In the current STEMI era, both total ischemic time and FMC-to-device times continue to be important factors associated with mortality.
Perspective:
This is a post hoc analysis from the landmark TOTAL trial evaluating the impact of thrombus aspiration among STEMI patients based on ischemic time. Similar to results of the main trial, thrombus aspiration did not result in improved clinical outcomes among patients with shorter ischemic times. There does not appear to be clinical benefit of thrombus aspiration among patients presenting with STEMI. Total ischemic time and prolonged FMC-to-device time were associated with increased cardiovascular mortality.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina
Keywords: Acute Coronary Syndrome, Anterior Wall Myocardial Infarction, Coronary Angiography, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, ST Elevation Myocardial Infarction, Thrombectomy, Thrombosis
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