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19 January 2017

STEMI – Thrombectomy and Pharmacology

Clare Appleby

Overview of contemporary data, controversies and UK clinical usage

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Summary

Summary of latest available evidence on thrombectomy, STEMI pharmacology  and trends in clinical usage.

The TAPAS trial, published in NEJM in 2008, was a single centre study in which 1071 STEMI patients were randomised to routine aspiration thrombectomy vs conventional therapy, with the primary end-point of myocardial blush grade (a surrogate end-point previously shown to correlate with mortality in the early days of primary angioplasty). In this trial aspiration thrombectomy was associated with a higher blush grade, indicating better reperfusion and better ST segment resolution. One year outcome data published in the Lancet also described a 3% mortality benefit, although though the original trial was not powered to determine this. A subsequent meta-analysis also showed benefit (largely driven by TAPAS) and a IIa indication for routine thrombectomy was adopted in the guidelines. However a number of negative trials followed in quick succession (TASTE, TOTAL), ultimately leading to the downgrading of this recommendation and a downward trend in usage as indicated by BCIS audit data. Ongoing issues include a potential associated increase in stroke indicated in a sub-analysis of TOTAL; both hemorrhagic and ischaemic with no clear mechanism and the potential for selection bias in the currently available data.

Current practice reflects a largely selective approach to the use of thrombectomy, reserved for particularly large thrombus burdens and other specific indications.

The debate around the most appropriate anti-thrombotic therapy to use in STEMI has been controversial and well documented. HORIZONS-AMI, published in 2008 in NEJM, demonstrated a mortality benefit with Bivalirudin over Heparin. Although a number of criticisms regarding the trial itself and broader applicability to contemporary practice (e.g. pre-potent anti-platelet era, high numbers of femoral cases etc.) have curtailed initial enthusiasm for its use, particularly in Europe. Moreover, a subsequent single-centre study (HEAT-PPCI) in the UK described higher MACE and stent thrombosis rates with Bivalirudin over Heparin.

The routine use of GPIIb/IIIa is similarly in decline in modern primary angioplasty centres.

 

 

 

 

Download

Summary

Summary of latest available evidence on thrombectomy, STEMI pharmacology  and trends in clinical usage.

The TAPAS trial, published in NEJM in 2008, was a single centre study in which 1071 STEMI patients were randomised to routine aspiration thrombectomy vs conventional therapy, with the primary end-point of myocardial blush grade (a surrogate end-point previously shown to correlate with mortality in the early days of primary angioplasty). In this trial aspiration thrombectomy was associated with a higher blush grade, indicating better reperfusion and better ST segment resolution. One year outcome data published in the Lancet also described a 3% mortality benefit, although though the original trial was not powered to determine this. A subsequent meta-analysis also showed benefit (largely driven by TAPAS) and a IIa indication for routine thrombectomy was adopted in the guidelines. However a number of negative trials followed in quick succession (TASTE, TOTAL), ultimately leading to the downgrading of this recommendation and a downward trend in usage as indicated by BCIS audit data. Ongoing issues include a potential associated increase in stroke indicated in a sub-analysis of TOTAL; both hemorrhagic and ischaemic with no clear mechanism and the potential for selection bias in the currently available data.

Current practice reflects a largely selective approach to the use of thrombectomy, reserved for particularly large thrombus burdens and other specific indications.

The debate around the most appropriate anti-thrombotic therapy to use in STEMI has been controversial and well documented. HORIZONS-AMI, published in 2008 in NEJM, demonstrated a mortality benefit with Bivalirudin over Heparin. Although a number of criticisms regarding the trial itself and broader applicability to contemporary practice (e.g. pre-potent anti-platelet era, high numbers of femoral cases etc.) have curtailed initial enthusiasm for its use, particularly in Europe. Moreover, a subsequent single-centre study (HEAT-PPCI) in the UK described higher MACE and stent thrombosis rates with Bivalirudin over Heparin.

The routine use of GPIIb/IIIa is similarly in decline in modern primary angioplasty centres.

 

 

 

 

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