Qu Yang-Yang, Zhang Xiao-Guo, Ju Cheng-Wei, Su Ya-Min, Zhang Rui, Zuo Wen-Jie, Ji Zhen-Jun, Chen Li-Juan, Ma Gen-Shan
Department of Cardiology, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China.
Front Cardiovasc Med. 2022 Feb 21;9:791007. doi: 10.3389/fcvm.2022.791007. eCollection 2022.
There are some controversies on the utilization and benefits of thrombus aspiration in patients with ST-segment elevation myocardial infarction (STEMI). However, a few studies investigated this issue and the age-associated effects among the large population in China. Hence, we aimed to figure out the age-associated utilization and in-hospital outcomes of thrombus aspiration to improve therapeutic decisions in clinical routine.
We retrospectively recruited 13,655 eligible STEMI patients from the database of the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome project. These subjects were allocated into primary percutaneous coronary intervention (PPCI)-only group and thrombus aspiration group after being subdivided into three age groups (G, G, and G). After 1:1 propensity score matching for PPCI-only and thrombus aspiration groups, a total of 8,815 matched patients were enrolled for the subsequent analysis. The primary outcome was in-hospital cardiovascular death, and the key safety outcome was in-hospital stroke.
We observed that the ratio of STEMI patients undergoing thrombus aspiration to PPCI-only reduced with aging. For patients ≤ 75 years, the culprit lesion suffered from thrombus aspiration was mainly located in the left anterior descending branch, and left-ventricular ejection fraction (LVEF) was lower (G: 54.9 ± 8.9 vs. 56.0 ± 8.7%, = 0.01; G: 53.9 ± 9.6 vs. 54.8 ± 9.0%, = 0.001) and the rate of regional wall motion abnormality was higher (G: 75.7 vs. 66.5%, < 0.001; G: 75.4 vs. 69.1%, < 0.001) in the thrombus aspiration group. By contrast, for patients > 75 years, the right coronary artery was the predominant culprit lesion undergoing thrombus aspiration, LVEF (63.1 ± 10.5 vs. 53.1 ± 9.5%, = 0.985) and the regional wall motion abnormality (79.2 vs. 74.2%, = 0.089) were comparable between the two treatment groups. Thrombus aspiration neither reduced the in-hospital risk of cardiovascular death, all-cause death, recurrent myocardial infarction, acute stent thrombosis, heart failure, cardiogenic shock, and sudden cardiac arrest nor increased stroke risk compared with the PPCI-only group. However, after adjustment for age, thrombus aspiration presented the tendency to reduce the incidence of sudden cardiac arrest (4.9 vs. 2.5%, = 0.06) and in-hospital cardiovascular death at 3 days (hazard ratio 0.46; 95% CI, 0.20-1.06; log-rank = 0.08) in G group and tended to increase the incidence of heart failure in G (5.7 vs. 6.9%, = 0.07).
The thrombus aspiration neither significantly reduced the in-hospital incidence of major adverse cardiac events nor increased stroke risk. However, it might play a protective role in reducing in-hospital sudden cardiac arrest and increasing survival from cardiovascular death at 3 days for the elderly.
ST段抬高型心肌梗死（STEMI）患者中血栓抽吸的应用及获益存在一些争议。然而，在中国大规模人群中，仅有少数研究调查了此问题及年龄相关影响。因此，我们旨在明确血栓抽吸的年龄相关应用情况及院内结局，以改善临床常规治疗决策。
我们从“中国心血管疾病医疗质量改善项目-急性冠状动脉综合征”数据库中回顾性招募了13655例符合条件的STEMI患者。这些受试者在被分为三个年龄组（G1、G2和G3）后，再被分配到单纯直接经皮冠状动脉介入治疗（PPCI）组和血栓抽吸组。在对单纯PPCI组和血栓抽吸组进行1:1倾向评分匹配后，共纳入8815例匹配患者进行后续分析。主要结局为院内心血管死亡，关键安全结局为院内卒中。
我们观察到，接受血栓抽吸的STEMI患者与单纯接受PPCI患者的比例随年龄增长而降低。对于≤75岁的患者，血栓抽吸的罪犯病变主要位于左前降支，且血栓抽吸组的左心室射血分数（LVEF）较低（G1组：54.9±8.9% vs. 56.0±8.7%，P = 0.01；G2组：53.9±9.6% vs. 54.8±9.0%，P = 0.001），节段性室壁运动异常发生率较高（G1组：75.7% vs. 66.5%，P < 0.001；G2组：75.4% vs. 69.1%，P < 0.001）。相比之下，对于>75岁的患者，血栓抽吸的主要罪犯病变为右冠状动脉，两组间的LVEF（分别为63.1±10.5%和53.1±9.5%，P = 0.985）和节段性室壁运动异常（分别为79.2%和74.2%，P = 0.089）相当。与单纯PPCI组相比，血栓抽吸既未降低院内心血管死亡、全因死亡、再发心肌梗死、急性支架血栓形成、心力衰竭、心源性休克和心脏骤停的风险，也未增加卒中风险。然而，在对年龄进行调整后，血栓抽吸有降低G1组心脏骤停发生率（4.9% vs. 2.5%，P = 0.06）及3天内院内心血管死亡的趋势（风险比0.46；95%CI，0.20 - 1.06；对数秩检验P = 0.08），且有增加G2组心力衰竭发生率的趋势（5.7% vs. 6.9%，P = 0.07）。
血栓抽吸既未显著降低院内主要不良心脏事件的发生率，也未增加卒中风险。然而，它可能对降低院内心脏骤停及提高老年患者3天内心血管死亡的生存率起到保护作用。
