Prognostic Significance of Coronary Thrombus in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes: A Subanalysis of the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) Trial

Sep 09, 2011
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Authors:
Goto K, Lansky AJ, Nikolsky E, et al., on behalf of the ACUITY Investigators.
Citation:
JACC Cardiovasc Interv 2011;4:769-777.
Summary By:
Hitinder S. Gurm, MBBS, FACC

Study Questions:

What are the incidence and implications of coronary thrombus in patients undergoing percutaneous coronary intervention (PCI) for non–ST-elevation acute coronary syndrome (NSTE-ACS)?

Methods:

The authors assessed the prevalence and impact of coronary thrombus on the outcome of 3,627 patients with NSTE-ACS who were enrolled in the angiographic substudy of the ACUITY trial. All patients had their baseline and final post-PCI angiograms analyzed by an independent angiographic core laboratory.

Results:

Coronary thrombus was seen in 15% of the patients. Preprocedural thienopyridines and glycoprotein (GP) IIb/IIIa inhibitors were associated with a lower incidence of thrombus. Patients with thrombus had lower rates of normal epicardial coronary flow post-PCI (final TIMI 3 flow 89.6% vs. 97.1%, p < 0.0001). Thrombus was an independent predictor of death (odds ratio [OR], 3.16; 95% confidence interval [CI], 1.20- 8.37; p = 0.02), and myocardial infarction at 30 days (OR, 1.62; 95% CI, 1.17-2.24; p = 0.003). Patients with thrombus had significantly higher rates of stent thrombosis (ST) compared with patients without thrombus at 30 days (2.8% vs. 1.1%; p = 0.002) and at 1 year (3.7% vs. 1.8%; p = 0.003). Thrombus was an independent predictor of ST at 30 days (OR, 2.61; 95% CI, 1.38-4.91) and 1 year (OR, 2.98; 95% CI, 1.64-5.42).

Conclusions:

Angiographic thrombus is associated with an adverse short- and long-term outcome in patients with NSTE-ACS.

Perspective:

The poor outcome associated with the presence of coronary thrombus has been established in multiple studies. This study corroborates the association in a relatively contemporary cohort and demonstrates the adverse prognostic implications of thrombus in patients with NSTE-ACS. The incidence of thrombus was lower in patients pre-treated with more potent antiplatelet agents, and a case can be made for more frequent use of upstream dual antiplatelet therapy. Further studies are warranted to assess if use of more potent agents such as prasugrel or ticagrelor would be associated with a better outcome in these patients.

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Platelet Aggregation Inhibitors, Thiophenes, Piperazines, Angioplasty, Percutaneous Coronary Intervention, Thienopyridines, Stents, Prevalence, Incidence, Thrombosis, Cardiology, Catheterization, Platelet Glycoprotein GPIIb-IIIa Complex


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