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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Impaired thrombolytic status predicts adverse cardiac events in patients undergoing primary percutaneous coronary
Christos Christopoulos, Mohamed Farag, Keith Sullivan
1Prof. Diana A. Gorog, Imperial College, London, UK, Tel.: +44 207 034 8934,
Insights
Assessing endogenous thrombolysis alongside platelet function identifies ST-elevation myocardial infarction patients at high risk for recurrent thrombosis. This finding could personalize antithrombotic therapy to reduce bleeding and improve cardiovascular outcomes.
Area of Science:
- Cardiovascular Medicine
- Hematology
- Thrombosis Research
Background:
- Antithrombotic medications are crucial for managing thrombosis but increase bleeding risk.
- Identifying ST-elevation myocardial infarction (STEMI) patients prone to recurrent thrombosis is key for personalized treatment strategies.
- Endogenous thrombolytic potential, not just platelet reactivity, may significantly impact outcomes after thrombus formation.
Purpose of the Study:
- To investigate if assessing both platelet reactivity and endogenous thrombolysis can identify STEMI patients at high risk for recurrent thrombotic events.
- To evaluate the predictive value of endogenous thrombolytic potential for major adverse cardiac events (MACE) in STEMI patients.
Main Methods:
- Assessed thrombotic status in STEMI patients using the Global Thrombosis Test (GTT) before and after primary percutaneous coronary intervention (PPCI), at discharge, and 30 days post-discharge.
- Measured occlusion time (OT) for thrombus formation and lysis time (LT) for endogenous thrombolysis under high shear conditions.
- Correlated OT and LT measurements with clinical outcomes, including MACE, cardiovascular death, spontaneous reperfusion, and ST-segment resolution over 12 months' follow-up.
Main Results:
- Impaired endogenous thrombolysis (prolonged LT ≥ 3000 s) was associated with increased MACE (HR: 3.31) and cardiovascular death (HR: 4.17).
- Enhanced endogenous thrombolysis (LT < 1000 s) correlated with spontaneous reperfusion and improved flow pre-PPCI.
- Shorter baseline OT was observed in patients with MACE, particularly recurrent myocardial infarction and stroke (p=0.017).
Conclusions:
- Impaired endogenous thrombolysis is a significant predictor of increased cardiovascular risk in STEMI patients.
- Enhanced endogenous thrombolysis is linked to spontaneous reperfusion, suggesting a role in favorable outcomes.
- Endogenous thrombolysis represents a potential novel target for pharmacological intervention and personalized antithrombotic therapy in high-risk STEMI patients.
Abstract:
Antithrombotic medications reduce thrombosis but increase bleeding. Identification of ST-elevation myocardial infarction (STEMI) patients at risk of recurrent thrombosis could allow targeted treatment with potent antithrombotic medications, with less potent agents in others, to reduce bleeding. Conventional platelet function tests assess platelet reactivity only, yet there is increasing evidence that endogenous thrombolytic potential determines outcome following thrombus initiation. We investigated whether assessing both platelet reactivity and endogenous thrombolysis, could identify STEMI patients at high-risk of recurrent thrombotic events. Thrombotic status was assessed in STEMI patients, before and after primary percutaneous coronary intervention (PPCI), at discharge and at 30 days; with 12 months' follow-up. The time to form an occlusive thrombus under high shear (occlusion time, OT), and time to restore flow by endogenous thrombolysis (lysis time, LT) was measured using the point-of-care Global Thrombosis Test (GTT) in the cardiac catheterisation laboratory. Impaired endogenous thrombolysis (prolonged LT ≥ 3000 s), seen in 13 % patients pre-PPCI, was related to major adverse cardiac events, MACE (HR: 3.31, 95 %CI: 1.02-10.78, p = 0.045), driven by cardiovascular death (HR: 4.17, 95 %CI: 0.99-17.51, p = 0.05). Enhanced (rapid) endogenous thrombolysis (LT < 1000 s) was associated with spontaneous reperfusion, ST-segment resolution and Thrombolysis In Myocardial Infarction 3 flow pre-PPCI. Baseline OT was shorter in those with MACE (especially recurrent myocardial infarction and stroke) than those without (253 ± 150 s vs 354 ± 134 s, p=0.017). Endogenous thrombolysis, when impaired, is associated with increased cardiovascular risk, and when enhanced, with spontaneous reperfusion. Endogenous thrombolysis may be a novel target for pharmacological intervention, and allow targeting of potent antithrombotic medications to high-risk patients.
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