#Timi 3 flow. trial
This landmark randomised trial of 17,187 patients compared streptokinase alone, aspirin alone, the combination of aspirin and streptokinase vs neither in patients with suspected acute myocardial infarction (AMI). The effectiveness of thrombolytic therapy has been well demonstrated in the Second international study of infarct survival (ISIS-2) study. The Effectiveness of Reperfusion Therapy – Early Success in Thrombus Management 10–13 The basis of this strategy is to restore epicardial blood flow either by the fibrinolysis of thrombus or by mechanical displacement of thrombus in the case of percutaneous coronary intervention (PCI). 9 Reperfusion therapy has become the cornerstone in the treatment of STEMI. 8 Plaque rupture usually produces combination of red (cross-linked fibrin and red blood cells) and white (platelet aggregates) thrombus. 1,7 Angiographic evidence of thrombus formation can be seen in more than 90 % of patients who present with ST elevation myocardial infarction (STEMI). The pathophysiology of acute coronary syndrome (ACS) is rupture or erosion of the fibrous cap overlying lipid rich plaques within the arterial tree.1 This event exposes pro-inflammatory substances, ultimately resulting in platelet aggregation and formation of obstructive thrombus. Mechanism of Acute Coronary Syndrome in the Formation of Thrombus The Importance of Thrombus in the Pathophysiology of ST Elevation Myocardial Infarction 6 This article will review the importance of thrombus in STEMI and approaches to management: mechanical and pharmacologic. However, even with modern primary PCI, distal embolisation of thrombus is common and about a third of patients have impaired microvascular perfusion despite TIMI 3 flow in infarct vessel. 2–5 This therapy, whether it be pharmacologic in the case of fibrinolysis or mechanical in the case of percutaneous coronary intervention (PCI), aims at restoring patency of the IRA and ultimately tissue perfusion. The institution of reperfusion therapy has revolutionised the care of patients with STEMI decreasing morbidity and mortality. 1 This is owed to insight into role that thrombus has in the obstruction of the infarct-related artery (IRA) and the subsequent cascade of the myocardial ischaemia, cell oedema and myocardial necrosis. Many advances have been made in the management of ST elevation myocardial infarction (STEMI) over the past three decades. Thrombus management remains an important area of research in STEMI. The Thrombectomy with PCI versus PCI alone in patients with STEMI undergoing primary PCI (TOTAL) trial (N=10,700) will determine if MT reduces important clinical events during PPCI. The TASTE trial had much lower than expected mortality and so was likely underpowered for modest but important treatment effects (20–30 % RRR). However, the largest randomised trial (Thrombus aspiration in ST-elevation myocardial infarction in Scandinavia trial, N=7021) showed no difference in mortality and only trends towards reduction in myocardial infarction (MI) and stent thrombosis.
#Timi 3 flow. manual
A single-centre trial (N=1071), the Thrombus aspiration during percutaneous coronary intervention in acute myocardial infarction study (TAPAS) trial showed a mortality reduction, which led guidelines to recommend routine manual aspiration. Manual thrombectomy (MT) improves MPG and reduces distal embolisation in meta-analyses of small trials. Despite initial enthusiasm, current evidence does not support routine use of Intracoronary over intravenous glycoprotein 2b3a inhibitors during PPCI for ST elevation myocardial infarction (STEMI) to improve clinical outcomes. Microvascular flow, as measured by myocardial blush grade (MPG), predicts mortality after PPCI. The major limitation of modern primary percutaneous coronary intervention (PPCI) is distal embolisation of thrombus and microvascular obstruction.
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