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Delayed vs. immediate stenting in STEMI with a high thrombus burden

A systematic review and meta-analysis

Verzögerte vs. unmittelbare Stentimplantation bei STEMI mit hoher Thrombuslast

Systematische Übersicht und Metaanalyse

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Abstract

Background

The results of several large-scale randomized controlled trials are controversial regarding the advantages of delayed stenting (DS) compared with immediate stenting (IS). We sought to determine whether DS has benefits for patients with ST-segment elevation myocardial infarction (STEMI) with a high thrombus burden compared with IS.

Methods

We systematically searched four electronic databases. Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow, TIMI myocardial blush grade (TMBG), complete ST-segment resolution (>70%), major adverse cardiac events (MACE), and major bleeding complications were studied as outcomes. Data analysis was performed using a random-effects model utilizing the Review Manager 5.3 software.

Results

Our meta-analysis included eight studies involving 744 patients. DS showed greater benefits than IS in terms of TIMI grade 3 flow (odds ratio [OR]: 5.09, 95% confidence interval [CI]: 1.98–13.02, p < 0.001), TMBG (OR: 4.17, 95% CI: 1.87–9.31, p < 0.001), complete ST-segment resolution (OR: 2.16, 95% CI: 1.36–3.43, p = 0.001), and MACE (OR: 0.48, 95% CI: 0.25–0.94, p = 0.03). No significant difference was observed regarding major bleeding events (OR: 1.76, 95% CI: 0.40–7.66, p = 0.45).

Conclusion

DS yielded satisfactory outcomes regarding myocardial tissue reperfusion, demonstrated by the improved TIMI flow grade, TMBG, complete ST-segment resolution, and decreased MACEs without increasing major bleeding events in patients with STEMI and a high thrombus burden. DS may be preferred to IS for treating patients with this characteristic presentation.

Zusammenfassung

Hintergrund

Die Ergebnisse verschiedener großangelegter randomisierter kontrollierter Studien sind widersprüchlich hinsichtlich der Vorteile verzögerter Stenteinlage („delayed stenting“, DS) verglichen mit unmittelbarer Stenteinlage („immediate stenting“, IS). Ziel der Autoren war, zu untersuchen, ob die DS Vorteile für Patienten mit ST-Strecken-Hebungs-Infarkt („ST-segment elevation myocardial infarction“, STEMI) mit einer hohen Thrombuslast im Vergleich zur IS aufweist.

Methoden

Die Autoren durchsuchten 4 elektronische Datenbanken systematisch. Als Endpunkte wurden ein Fluss des Grades 3 gemäß Thrombolysis in Myocardial Infarction (TIMI), der Myokardperfusionsgrad gemäß TIMI („TIMI myocardial blush grade“, TMBG), die vollständige Rückbildung der ST-Stecken-Hebung (>70%), schwere unerwünschte kardiale Ereignisse („major adverse cardiac events“, MACE) und schwere Blutungskomplikationen untersucht. Die Datenanalysis erfolgte unter Verwendung eines Random-Effects-Modells mit der Software Review Manager 5.3.

Ergebnisse

Die vorliegende Metaanalyse umfasste 8 Studien mit 744 Patienten. Eine DS erbrachte größere Vorteile als eine IS in Bezug auf einen Fluss des Grades 3 gemäß TIMI (Odds Ratio, OR: 5,09; 95%-Konfidenzintervall, 95%-KI: 1,98–13,02; p < 0,001), TMBG (OR: 4,17; 95%-KI: 1,87–9,31; p < 0,001), vollständige Rückbildung der ST-Strecken-Hebung (OR: 2,16; 95%-KI: 1,36–3,43; p = 0,001) und MACE (OR: 0,48; 95%-KI: 0,25–0,94; p = 0,03). Es fand sich kein signifikanter Unterschied hinsichtlich schwererer Blutungen (OR: 1,76; 95%-KI: 0,40–7,66; p = 0,45).

Schlussfolgerung

Die DS führte zu zufriedenstellenden Ergebnissen in Bezug auf die Reperfusion des Myokards; dies zeigte sich durch eine Verbesserung beim TIMI-Flussgrad, TMBG, bei der vollständigen Rückbildung der ST-Strecken-Hebung und weniger MACE ohne zunehmende schwerere Blutungen bei Patienten mit STEMI und einer hohen Thrombuslast. Die DS ist möglicherweise gegenüber der IS bei der Behandlung von Patienten mit solchen typischen Symptomen zu bevorzugen.

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Abbreviations

CI:

Confidence interval

DS:

Delayed stenting

GPIs:

Glycoprotein IIb/IIIa inhibitors

IRA:

Infarct-related artery

IS:

Immediate stenting

MACE:

Major adverse cardiac event

MI:

Myocardial infarction

MVO:

Microvascular obstruction

OR:

Odds ratio

PCI:

Percutaneous coronary intervention

RCT:

Randomized controlled trial

STEMI:

ST-segment elevation myocardial infarction

TIMI:

Thrombolysis in Myocardial Infarction

TMBG:

TIMI myocardial blush grade

References

  1. Ibanez B, James S, Agewall S et al (2017) 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 39(2):119–177. https://doi.org/10.1093/eurheartj/ehx393

    Article  Google Scholar 

  2. Brosh D, Assali AR, Mager A et al (2007) Effect of no-reflow during primary percutaneous coronary intervention for acute myocardial infarction on six-month mortality. Am J Cardiol 99:442–445

    Article  Google Scholar 

  3. Erbel R, Heusch G (1999) Coronary microembolization–its role in acute coronary syndromes and interventions. Herz 24:558–575

    Article  CAS  Google Scholar 

  4. Escobar J, Guarda E, Marchant E et al (2001) Relation of stenting to decreased coronary blood flow during primary angioplasty in acute myocardial infarction. Am J Cardiol 88:1410–1412

    Article  CAS  Google Scholar 

  5. Harbaoui B, Courand PY, Besnard C et al (2015) Deferred vs immediate stenting in ST elevation myocardial infarction: potential interest in selected patients. Presse Med 44:e331–e339

    Article  Google Scholar 

  6. Henriques JP, Zijlstra F, Ottervanger JP et al (2002) Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J 23:1112–1117

    Article  CAS  Google Scholar 

  7. Sianos G, Papafaklis MI, Daemen J et al (2007) Angiographic stent thrombosis after routine use of drug-eluting stents in ST-segment elevation myocardial infarction: the importance of thrombus burden. J Am Coll Cardiol 50:573–583

    Article  CAS  Google Scholar 

  8. Dingli PF, Escaned J (2017) Minimalist immediate mechanical intervention in acute ST-segment elevation myocardial infarction: is it time to redefine targets? Cardiovasc Diagn Ther 7:4–10

    Article  Google Scholar 

  9. Freixa X, Belle L, Joseph L et al (2013) Immediate vs. delayed stenting in acute myocardial infarction: a systematic review and meta-analysis. EuroIntervention 8:1207–1216

    Article  Google Scholar 

  10. Ohman EM, Califf RM, Topol EJ et al (1990) Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction. TAMI Study Group. Circulation 82:781–791

    Article  CAS  Google Scholar 

  11. Carrick D, Oldroyd KG, McEntegart M et al (2014) A randomized trial of deferred stenting versus immediate stenting to prevent no- or slow-reflow in acute ST-segment elevation myocardial infarction (DEFER-STEMI). J Am Coll Cardiol 63:2088–2098

    Article  Google Scholar 

  12. De Maria GL, Alkhalil M, Oikonomou EK et al (2017) Role of deferred stenting in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention: a systematic review and meta-analysis. J Interv Cardiol 30:264–273

    Article  Google Scholar 

  13. Lee JM, Rhee TM, Chang H et al (2017) Deferred versus conventional stent implantation in patients with acute ST-segment elevation myocardial infarction: an updated meta-analysis of 10 studies. Int J Cardiol 230:509–517

    Article  Google Scholar 

  14. Qiao J, Pan L, Zhang B et al (2017) Deferred versus immediate stenting in patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis. J Am Heart Assoc 6(3):e4838. https://doi.org/10.1161/JAHA.116.004838

    Article  PubMed  PubMed Central  Google Scholar 

  15. Belle L, Motreff P, Mangin L et al (2016) Comparison of immediate with delayed stenting using the minimalist immediate mechanical intervention approach in acute ST-segment-elevation myocardial infarction: the MIMI study. Circ Cardiovasc Interv 9:e3388

    Article  Google Scholar 

  16. Kim JS, Lee HJ, Yu CW et al (2016) INNOVATION study (impact of immediate stent implantation versus deferred stent implantation on infarct size and microvascular perfusion in patients with ST-segment-elevation myocardial infarction). Circ Cardiovasc Interv 9(12):e4101

    Article  Google Scholar 

  17. Kelbaek H, Hofsten DE, Kober L et al (2016) Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3‑DEFER): an open-label, randomised controlled trial. Lancet 387:2199–2206

    Article  Google Scholar 

  18. Gibson CM, de Lemos JA, Murphy SA et al (2001) Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction: a TIMI 14 substudy. Circulation 103:2550–2554

    Article  CAS  Google Scholar 

  19. Mehran R, Rao SV, Bhatt DL et al (2011) Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 123:2736–2747

    Article  Google Scholar 

  20. Dias S, Welton NJ, Sutton AJ et al (2013) Evidence synthesis for decision making 4: inconsistency in networks of evidence based on randomized controlled trials. Med Decis Making 33:641–656

    Article  Google Scholar 

  21. Hu LQ, Gu Y, Zeng K, Gao B (2011) Clinical outcomes of primary stenting versus delayed stenting in patients with acute ST elevation myocardial infarction after successful percutaneous transtuminal coronary angioplasty. Shanghai Med J 34(1):54–57

    CAS  Google Scholar 

  22. Wu ZY, Sheng GT, Zhu ZN et al (2015) Comparison for the effects between emergent and delayed Stent implantation in patients with STEMI after thrombus extraction. Chin Circ J 30(4):317–321

    CAS  Google Scholar 

  23. Luo XL, Liu Q, Wang LL et al (2014) Outcomes of delayed stent implantation in ST segment elevation acute myocardial infarction with high thrombus burden. Chin J Intervent Cardiol 22(11):697–701

    Google Scholar 

  24. Yin D, Zhu H, Zhou X et al (2011) Delayed stent implantation following primary percutaneous coronary intervention for st elevation myocardial infarction in patients with severe massive thrombus. Heart 97:A147

    Article  Google Scholar 

  25. Meneveau N, Seronde MF, Descotes-Genon V et al (2009) Immediate versus delayed angioplasty in infarct-related arteries with TIMI III flow and ST segment recovery: a matched comparison in acute myocardial infarction patients. Clin Res Cardiol 98:257–264

    Article  Google Scholar 

  26. Ke D, Zhong W, Fan L, Chen L (2012) Delayed versus immediate stenting for the treatment of ST-elevation acute myocardial infarction with a high thrombus burden. Coron Artery Dis 23:497–506

    Article  Google Scholar 

  27. Cafri C, Svirsky R, Zelingher J et al (2004) Improved procedural results in coronary thrombosis are obtained with delayed percutaneous coronary interventions. J Invasive Cardiol 16:69–71

    PubMed  Google Scholar 

  28. Keeley EC, Boura JA, Grines CL (2003) Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 361:13–20

    Article  Google Scholar 

  29. Rezkalla SH, Kloner RA (2008) Coronary no-reflow phenomenon: from the experimental laboratory to the cardiac catheterization laboratory. Catheter Cardiovasc Interv 72:950–957

    Article  Google Scholar 

  30. Lago IM, Novaes GC, Badran AV et al (2016) In-lab Upfront use of tirofiban may reduce the occurrence of no-reflow during primary percutaneous coronary intervention. A pilot randomized study. Arq Bras Cardiol 107:403–410

    PubMed  PubMed Central  Google Scholar 

  31. Pu J, Mintz GS, Biro S et al (2014) Insights into echo-attenuated plaques, echolucent plaques, and plaques with spotty calcification: novel findings from comparisons among intravascular ultrasound, near-infrared spectroscopy, and pathological histology in 2,294 human coronary artery segments. J Am Coll Cardiol 63:2220–2233

    Article  Google Scholar 

  32. Niccoli G, Burzotta F, Galiuto L, Crea F (2009) Myocardial no-reflow in humans. J Am Coll Cardiol 54:281–292

    Article  Google Scholar 

  33. Bouleti C, Mewton N, Germain S (2015) The no-reflow phenomenon: state of the art. Arch Cardiovasc Dis 108:661–674

    Article  Google Scholar 

  34. Constantinides S, Lo TS, Been M, Shiu MF (2002) Early experience with a helical coronary thrombectomy device in patients with acute coronary thrombosis. Heart 87:455–460

    Article  CAS  Google Scholar 

  35. Vlaar PJ, Svilaas T, van der Horst IC et al (2008) Cardiac death and reinfarction after 1 year in the thrombus aspiration during percutaneous coronary intervention in acute myocardial infarction study (TAPAS): a 1-year follow-up study. Lancet 371:1915–1920

    Article  Google Scholar 

  36. Jolicoeur EM, Tanguay JF (2011) From primary to secondary percutaneous coronary intervention: the emerging concept of early mechanical reperfusion with delayed facilitated stenting-when earlier may not be better. Can J Cardiol 27:529–533

    Article  Google Scholar 

  37. Guagliumi G, Costa MA, Sirbu V et al (2011) Strut coverage and late malapposition with paclitaxel-eluting stents compared with bare metal stents in acute myocardial infarction: optical coherence tomography substudy of the harmonizing outcomes with revascularization and stents in acute myocardial infarction (HORIZONS-AMI) trial. Circulation 123:274–281

    Article  CAS  Google Scholar 

  38. Mester P, Bouvaist H, Delarche N et al (2017) At least seven days delayed stenting using minimalist immediate mechanical intervention (MIMI) in ST-segment elevation myocardial infarction: the SUPER-MIMI study. EuroIntervention 13:390–396

    Article  Google Scholar 

  39. Marquis-Gravel G, Jolicoeur EM (2016) The value of deferred stenting in acute myocardial infarction: can minimalist immediate mechanical intervention do it all? Can J Cardiol 32:935–937

    Article  Google Scholar 

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Acknowledgements

We thank all patients who participated in the original studies and the authors providing the relevant data.

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Authors and Affiliations

  1. Department of Cardiology, The Third Hospital of Hebei Medical University, NO.139 Ziqiang Road, Qiaoxi District, 050051, Shijiazhuang, China

    B. Sun MD, H. Yin MD, Z. Liu MD, T. Chen MD, J. Li MD, C. Guo MD &  Z. Jiang MD

  2. Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, NO.238 Xiangya Road, Kaifu District, 410078, Changsha, China

    J. Liu MD

  3. Center for Disease Control and Prevention of Hebei Province; NO.97 Huaian Road, Department of Epidemiology and Health Statistics, Yuhua District, 050021, Shijiazhuang, China

    S. Yang MD

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Correspondence to Z. Jiang MD.

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B. Sun, J. Liu, H. Yin, S. Yang, Z. Liu, T. Chen, J. Li, C. Guo, and Z. Jiang declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Binjie Sun and Jiaofeng Liu contributed equally to this work.

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Sun, B., Liu, J., Yin, H. et al. Delayed vs. immediate stenting in STEMI with a high thrombus burden. Herz 44, 726–734 (2019). https://doi.org/10.1007/s00059-018-4699-x

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