Cardiology Department, Royal Free London NHS Foundation Trust, London, UK.
The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, New York, USA.
Catheter Cardiovasc Interv. 2022 Feb;99(3):641-649. doi: 10.1002/ccd.30008. Epub 2021 Nov 12.
Plaque rupture leads to a cascade of events culminating in collagen disruption, tissue factor release, platelet activation and thrombus formation. Pro-inflammatory conditions, hyperglycemia and smoking predispose to high thrombus burden (HTB) which is an independent predictor of slow or no-reflow. In patients with acute myocardial infarction (AMI), glycoprotein IIb/IIIa inhibitors (GPI) reduce thrombus burden and improve myocardial perfusion. These agents are typically administered systemically via the intravenous route or locally via an intracoronary (IC) route. However, as higher local concentrations of GPI are associated with enhanced platelet inhibition, intralesional (IL) GPI administration may be particularly effective in cases of HTB. Modest-sized randomized trials comparing IL and IC GPI delivery have reported conflicting outcomes. Some trials have demonstrated improved coronary flow and myocardial perfusion with reduced major adverse cardiac events with IL compared with IC GPI administration, whereas others have shown no significant benefits. Furthermore, although no direct comparison has been made between IL delivery using an aspiration catheter, microcatheter or a dedicated balloon-based "weeping" infusion-catheter, improved outcomes have been most consistent following GPI administration at the site of the lesion and thrombus with the dedicated infusion catheter. This review provides an update on the role and outcomes of IL GPI administration in patients with AMI and HTB. Based on the evidence we offer an algorithm demonstrating when to consider IL administration in patients with AMI undergoing intervention. We conclude with a perspective on the management of patients with STEMI and COVID-19 in whom a prothrombotic state often results in HTB.
斑块破裂导致一系列事件的级联反应，最终导致胶原破坏、组织因子释放、血小板激活和血栓形成。促炎状态、高血糖和吸烟使血栓负荷增加（HTB），HTB 是慢血流或无复流的独立预测因素。在急性心肌梗死（AMI）患者中，糖蛋白 IIb/IIIa 抑制剂（GPI）可降低血栓负荷并改善心肌灌注。这些药物通常通过静脉途径全身给药，或通过冠状动脉内（IC）途径局部给药。然而，由于 GPI 的局部浓度越高，血小板抑制作用越强，因此局部内（IL）GPI 给药在 HTB 情况下可能特别有效。比较 IL 和 IC GPI 给药的适度规模随机试验报告了相互矛盾的结果。一些试验表明，与 IC GPI 给药相比，IL 给药可改善冠状动脉血流和心肌灌注，减少主要不良心脏事件，而其他试验则没有显示出显著益处。此外，尽管尚未对使用抽吸导管、微导管或专用球囊“渗出”输注导管进行 IL 给药进行直接比较，但在病变和血栓部位使用专用输注导管进行 GPI 给药后，结果改善最为一致。本综述提供了关于 AMI 和 HTB 患者中 IL GPI 给药的作用和结果的最新信息。根据我们提供的证据，提出了一个算法，用于在接受介入治疗的 AMI 患者中考虑何时进行 IL 给药。最后，我们将讨论管理 STEMI 和 COVID-19 患者的观点，这些患者通常处于促血栓状态，导致 HTB。
