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Routine Thrombus Aspiration: Another Negative Trial

Summary and Comment |
September 1, 2013

Routine Thrombus Aspiration: Another Negative Trial

  1. Howard C. Herrmann, MD

Thrombus aspiration before percutaneous coronary intervention showed no mortality advantage over PCI alone at 30 days in patients with ST-segment-elevation MI.

  1. Howard C. Herrmann, MD

Thrombus aspiration before primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) has intuitive appeal. That has prompted several randomized trials of the approach, most of them small and with conflicting results. Now, in a large registry-based trial, 7244 patients (about 60% of the STEMI patients at all 29 centers in Sweden, plus one center each in Denmark and Iceland) were randomized to undergo pre-PCI manual thrombus aspiration or PCI alone.

All-cause mortality at 30 days, the primary endpoint, was similar in the two groups: 2.8% for thrombus aspiration and 3.0% for PCI alone (hazard ratio, 0.94; 95% confidence interval, 0.72–1.22; P=0.63). This difference remained nonsignificant after accounting for the 5% to 6% of patients who did not receive the assigned therapy and in all prespecified demographic, clinical, and antiplatelet- and antithrombotic-drug subgroups. Rates of both stent thrombosis and rehospitalization for reinfarction were 50% lower with thrombus aspiration than with PCI, but these differences did not reach statistical significance. The two groups had similar rates of stroke, left-ventricular dysfunction at discharge, and target-vessel revascularization, as well as a similar mean hospital stay.

Comment

Given these findings, routine use of thrombus aspiration before primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction should be discouraged. Notably, subgroups often considered outliers (e.g., those with proximal or left anterior descending lesions, patients with a large thrombus burden) also did not benefit. It is possible, however, that a benefit of aspiration could become apparent with longer follow-up, which is imperative to track. Finally, this trial introduces a unique study design — namely, randomization within an online, large-scale, comprehensive, national clinical-quality registry. Nonetheless, the design is limited in its lack of event adjudication and blinding to therapy.

To join a discussion of these findings, read Harlan Krumholz's interview with Dr. Fröberton CardioExchange, an online community hosted by the New England Journal of Medicine and NEJM Journal Watch and dedicated to improving cardiac patient care. Membership is free for medical professionals.

  • Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; St. Jude Medical Speaker's bureau American College of Cardiology Foundation; Cardiovascular Institute; Cardiovascular Research Foundation; Christiana Medical Center; Coastal Cardiovascular Society; Crozer-Chester Hospital; Mayo Clinic; New York Cardiology Society Equity Micro-Interventional Devices, Inc. Grant / research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical Editorial boards Catheterization and Cardiovascular Interventions; Circulation-Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology

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