Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1-year follow-up of the prospective randomised TOTAL trial

The Lancet, Volume 387, Issue 10014, 9–15 January 2016, Pages 97-98


Two large trials have reported contradictory results at 1 year after thrombus aspiration in ST elevation myocardial infarction (STEMI). In a 1-year follow-up of the largest randomised trial of thrombus aspiration, we aimed to clarify the longer-term benefits, to help guide clinical practice.

Methods
The trial of routine aspiration ThrOmbecTomy with PCI versus PCI ALone in Patients with STEMI (TOTAL) was a prospective, randomised, investigator-initiated trial of routine manual thrombectomy versus percutaneous coronary intervention (PCI) alone in 10 732 patients with STEMI.

Eligible adult patients (aged ≥18 years) from 87 hospitals in 20 countries were enrolled and randomly assigned (1:1) within 12 h of symptom onset to receive routine manual thrombectomy with PCI or PCI alone. The trial did not show a difference at 180 days in the primary outcome of cardiovascular death, myocardial infarction, cardiogenic shock, or heart failure.

In this longer-term follow-up of the TOTAL study, we report the results on the primary outcome (cardiovascular death, myocardial infarction, cardiogenic shock, or heart failure) and secondary outcomes at 1 year.

Findings

Between Aug 5, 2010, and July 25, 2014, 10 732 eligible patients were enrolled and randomly assigned to thrombectomy followed by PCI (n=5372) or to PCI alone (n=5360).
The primary outcome at 1 year occurred in 395 (8%) of 5035 patients in the thrombectomy group compared with 394 (8%) of 5029 in the PCI alone group (hazard ratio [HR] 1·00 [95% CI 0·87–1·15], p=0·99).
Cardiovascular death within 1 year occurred in 179 (4%) of the thrombectomy group and in 192 (4%) of 5029 in the PCI alone group (HR 0·93 [95% CI 0·76–1·14], p=0·48). The key safety outcome, stroke within 1 year, occurred in 60 patients (1·2%) in the thrombectomy group compared with 36 (0·7%) in the PCI alone group (HR 1·66 [95% CI 1·10–2·51], p=0·015).

Interpretation

Routine thrombus aspiration during PCI for STEMI did not reduce longer-term clinical outcomes and might be associated with an increase in stroke.
As a result, thrombus aspiration can no longer be recommended as a routine strategy in STEMI.

G Mohan.

Hi Mohan
Thank you for this thought provoking article. The results show that the adverse effect is worse than the original disease. It is a common sight in the casualty rooms when a patient comes with vague chest complaints and in a relatively stable condition collapses immediately after we institute some radical treatment. Most of us would have had experience of this sort in our clinical practice. I have seen patients collapsing with sublingual administration of nifidipine or nitrates more so when they are in unstable condition in the early hours of acute hypertensive crisis or acute coronary syndrome. First dose hypotension is a notorious complication. My usual advice to resident medical officers is that it is better to give nitrates or antihypertensive drugs in the form IV drip which should be given slowly. Here we have control over the infusion and can titrate the dose according to the need of the patient whereas when given orally or more so sublingually we have no control over the medicine. The same is true in the case of intervention rooms also. When we meddle with the thrombus in a coronary artery it gets broken and displaced and may go further and cause acute blocks in the distal parts of the vessel. Acute block is very dangerous and may be fatal too. And such patients are usually on anticoagulants and at the sight of the dislodgement of the thrombus there may be excess bleeding which cannot be controlled and the results would be catastrophic.

Keeping this in mind I want to bring your attention to an incident that took place about 2 weeks ago. A senior doctor had come from USA to Tamil Nad to see his class mates. After the function most of his friends had left the place. He was to go to his native place which was only a few kilometres away to see his elder brother that day. After his breakfast he was standing near the lift to go up to his room. That time someone nearby noted that he was unwell and about to fall. Immediately the hotel staff rushed to him and recognised him and wanted to take him to a nearby hospital. But our friend though in a drowsy state, refused to oblige them and insisted to go up to the room. I am not sure whether that time his wife was with him. On reaching his room he collapsed on the bed. The hospital staff knew that there was one doctor who belonged to the same group staying in the same floor and immediately went to his room and brought him. The doctor friend who was not in good form due to his own spinal ailment was shocked to see his colleague in a bad shape. He did not have any tools with him. When he found his peripheral and carotid pulse not palpable and his friend was totally unconscious and not responding to his calls, with a good presence of mind, he gave him a chest compression and behold, to the great relief to all standing nearby, our friend opened his eyes and looked around and got up and went to the wash basin and vomited. With that he became normally looking. He said he was all right. Not willing to go to any hospital. But upon persuasion he obliged to go. Even here when they wanted to bring an ambulance he insisted to go by a car and he did go by a car. What happened afterward was only a hearsay. I understand that on reaching there after preliminary examinations and an angiogram done which showed 2 or 3 vessels showed blocks and it seemed they did some intervention. Was it a thrombus aspiration? I am not sure. And it seemed he immediately collapsed and died.

I don’t intend to sit on judgement over what had happened that day to our dear doctor. Everything done was with good intention. But I want to place my opinion with all humility. In the first place what would have happened to him? In all probability, with sudden fainting and total absence of all the peripheral and carotid pulses and in the absence of breathlessness or without much distress, I am tempted to think it was a case of pulseless ventricular tachycardia, a case of electric failure resulting in collapse of pumping of left ventricle which would have affected perfusion of brain. With the one chest compression by the experienced doctor which was like a DC shock, the entire picture returned to the normal state. What a great thing! And this friend of ours went to the hospital in a car in a fully conscious state with no trace of any disability. The doctor friend who was the reason for this dramatic recovery could not accompany him due to his own plan to leave that day itself. I don’t know whether the doctors at the hospital were aware of the entire event that took place in the morning in the hotel. Whether the hospital staff was in a mood to take the entire history or the people who accompanied the doctor was able to narrate what happened earlier in a clear manner. Everything is Gods Will.

Now Mohan, it is up to anyone to interpolate the result of the study you posted on what happened to our beloved colleague and infer one's own conclusion. I think reason and logic must take precedence over a set of protocol in the management of a patient

UA Mohammed

Dear Mohammed,

It is extremely difficult to judge or assess as to what happened to our friend and how exactly he was managed and treated after he collapsed. We will try and get the full story before we discuss the matter further. Trying to come to a conclusion before we have all the facts may do injustice to someone who tried to help our friend. However it is most important for us to probe the matter further and discuss what should and should not have been done.

Your post and Mohan's post I must say is very thought provoking. When someone has recovered consciousness after collapsing they will ofcourse need full investigation. But rushing to treat them by some modern technique because the treatment mode is available needs questioning. Should one not consider stabilizing the patient immediately by conservative means and plan on definitive treatment when everyone can think rationally. I am not involved with treating patients after an MI. However what I would like to know is, when someone collapses after an MI but recovers consciousness soon after through CPR or electrical stimulation, how should one go about treating them. I am aware that when you suspect an MI soluble aspirin should be administered immediately before transporting them to hospital. I also know that cardiac care units will try and insert a stent as soon as possible. Will they do this even when the patient is conscious and reasonably stable? Also when the patient is wheeled in for an angiogram is it not mandatory for a cardiac surgeon to be on standby for an open procedure in case the patient collapses and has an arrest during the procedure? There are many questions and many things we need to know.

Badri