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Incidence and Predictors of Left Ventricular Thrombus After Primary Percutaneous Coronary Intervention for Anterior
Adam Driesman1, Omar Hyder1, Christopher Lang1
1Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island.
Insights
Left ventricular thrombus is found in 15% of anterior ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Cardiac arrest is the only independent predictor of thrombus risk, indicating a need for better prediction models.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Research
Background:
- The use of warfarin in anterior ST-elevation myocardial infarction (STEMI) with left ventricular (LV) dysfunction post-primary percutaneous coronary intervention (PCI) and dual antiplatelet therapy remains uncertain.
- Warfarin may prevent cardioembolic events but increases bleeding risk with dual antiplatelet therapy.
Purpose of the Study:
- To assess the incidence of LV thrombus in anterior STEMI patients undergoing primary PCI.
- To identify clinical predictors for LV thrombus in this patient population.
Main Methods:
- A retrospective study of 687 anterior STEMI patients treated with primary PCI (2006-2013).
- Echocardiographic criteria identified 310 high-risk patients for LV thrombus analysis.
- Logistic regression was used to evaluate baseline and treatment variables.
Main Results:
- The incidence of LV thrombus was 15% (47 patients).
- Cardiac arrest was the sole independent predictor of increased LV thrombus risk (OR: 4.06).
- Trends suggested lower risk with cardiogenic shock and baseline aspirin use; higher risk with unfractionated heparin post-PCI and balloon angioplasty without stent.
Conclusions:
- Predicting definite LV thrombus in anterior STEMI with LV dysfunction after primary PCI is difficult.
- Further research is required to identify patient subsets who may benefit from prophylactic warfarin.
Background:
The role of warfarin in anterior ST-segment elevation myocardial infarction (STEMI) complicated by left ventricular (LV) dysfunction in patients treated with primary percutaneous coronary intervention (PCI) and dual antiplatelet therapy is unclear. Warfarin may prevent cardioembolic events but significantly increases bleeding in the setting of dual antiplatelet therapy.
Hypothesis:
The incidence of LV thrombus in anterior STEMI patients treated with PCI is low, and clinical predictors might be valuable in determining patients at risk.
Methods:
We performed a retrospective, single-center study of 687 consecutive patients with anterior STEMI treated with PCI from 2006 to 2013. Baseline variables were evaluated in 310 patients at high risk for LV thrombus based on echocardiographic criteria. Patients with definite, probable, and no LV thrombus were compared by ANOVA, χ(2), or t test where appropriate. Logistic regression analysis was performed.
Results:
The incidence of LV thrombus was 15% (n = 47 probable/definite thrombus). Cardiac arrest was the only independent characteristic associated with increased risk of LV thrombus (odds ratio [OR]: 4.06, 95% confidence interval [CI]: 1.3-12.7). Trends were observed for a lower risk in cardiogenic shock (OR: 0.33, 95% CI: 0.10-1.05) and aspirin use at baseline (OR: 0.43, 95% CI: 0.17-1.1). Treatment variables associated with LV thrombus included unfractionated heparin use post-PCI (OR: 2.43, 95% CI: 1.16-5.1) and use of balloon angioplasty without stent.
Conclusions:
In contemporary practice with primary PCI, definite LV thrombus following anterior STEMI with LV dysfunction is challenging to predict. Further investigation is needed to determine if there is a subset of patients that should be treated with prophylactic warfarin.
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