In the early days of percutaneous coronary intervention (PCI) in patients with ST elevation acute myocardial infarction (STEMI), no reflow phenomenon was known as an indicator of the worst possible outcomes in terms of left ventricular remodeling, infarct size, ejection fraction and mortality, at long term.
The TOTAL study (Routine Aspiration Thrombectomy with PCI Versus PCI Alone in Patients With STEMI Undergoing Primary PCI), comparing manual thrombus aspiration vs. primary PCI alone, did no show significant differences as regards cardiovascular death, repeat MI, cardiogenic shock or NYHA class IV cardiac failure. However, there was increased risk of stroke in the manual thrombectomy group.
The aim of this post hoc analysis from the multicenter, randomized TOTAL study, was to assess the effect of manual thrombectomy on no reflow outcomes across different subgroups. The study also looked at the link between no reflow and major cardiovascular events at one year, and sought to determine the clinical predictors of no reflow.
Primary end point was the composite of cardiovascular death, repeat MI, cardiogenic shock and NYHA class IV cardiac failure. Secondary end point included all-cause mortality, rehospitalization for any cause, and stent thrombosis.
The analysis included 1800 patients, 10.9% presenting no reflow. Patients in this group were older (64,4 vs 60,8 p <0,01), and mostly men. They more often presented a higher class of Killip Kimball, lower TIMI flow before PCI and less use of direct stenting.
Patients randomized to manual thrombectomy presented 10,7% no reflow rate, while the PCI group presented 11,1% rate (odds ratio [OR] 0,95, CI 95%: 0,71-1,28; p = 0,76). Patients undergoing direct stenting, in the thrombectomy group, showed a lower incidence of no reflow vs. the PCI group (5,1% vs 9,7%, OR 0,50, CI 95%: 0,26-0,96).
At one year, patients experiencing no reflow had a 70% increased relative risk of primary end point (15,8% vs 6,3%, HR 1,70, CI 95%: 1,13-2,56; p = 0,01). Also, no reflow was associated with higher risk of cardiogenic shock (8,2% vs 1,7%, HR 2,20, CI 95%: 1,14-4,24, p = 0,02). No flow predictors were identified as: age (OR 1,25, CI 95%: 1,09-1,42; p = 0,001), TIMI flow 3 prior PCI (OR 0,33, CI 95%: 0,19-0,56; p < 0,0001) and direct stenting (OR 0,66, CI 95%: 0,45-0,95, p = 0,03).
Conclusion
This analysis has shown that manual thrombectomy did not reduce no reflow in all patients, but when combined with direct stenting there might be synergy. No reflow is associated with increased adverse clinical events. More studies are required to better assess the link between no reflow and direct stenting.
Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.
Original Title: No-reflow after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction: an angiographic core laboratory analysis of the TOTAL Trial.
Reference: Marc-André d’Entremont MD, MPH et al EuroIntervention 2023;19.
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