Sonothrombolysis in Patients With ST-Elevation Myocardial Infarction With Electrocardiographic No-Reflow After
Soufiane El Kadi1, Mariëlle C van de Veerdonk1, Eva M Spoormans1
1Amsterdam UMC, Location VUmc, Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
Insights
Post-PCI sonothrombolysis did not improve ST resolution or reduce infarct size in STEMI patients with persistent ST elevation. This intervention did not significantly impact clinical outcomes in this high-risk group.
Area of Science:
- Cardiology
- Interventional Cardiology
- Biomedical Engineering
Background:
- ST-elevation myocardial infarction (STEMI) often involves microvascular no-reflow after percutaneous coronary intervention (PCI).
- Sonothrombolysis has shown potential in reducing infarct size and improving left ventricular function in STEMI patients.
- Persistent ST elevation post-PCI indicates ongoing myocardial damage and risk.
Purpose of the Study:
- To evaluate the efficacy of post-PCI sonothrombolysis in STEMI patients with persistent ST elevation.
- To determine if sonothrombolysis can reduce no-reflow and infarct size in this specific patient subgroup.
- To assess the impact on ST resolution, myocardial perfusion, and clinical outcomes.
Main Methods:
- Randomized controlled trial involving STEMI patients with <12 hours symptom onset and persistent ST elevation after primary PCI.
- Patients were randomized to receive either sonothrombolysis or standard care (control).
- Primary endpoint: summed ST elevation at 60 minutes; secondary endpoints: infarct size, perfusion, LV function, and 6-month clinical outcomes via CMR and follow-up.
Main Results:
- No significant difference in summed ST elevation between sonothrombolysis and control groups (P=.50).
- Complete ST resolution rates were not significantly different (40% vs 19%, P=.16).
- Infarct size, myocardial perfusion, LV ejection fraction, and 6-month clinical outcomes were comparable between groups.
Conclusions:
- Post-PCI sonothrombolysis did not improve ST resolution or reduce infarct size in STEMI patients with persistent ST elevation.
- The incidence of major adverse clinical events was low in this high-risk population.
- Further research may be needed to identify optimal strategies for managing persistent ST elevation post-PCI.
Background And Aims:
Approximately 50% of patients with ST elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) experience microvascular no-reflow. Pre- and post-PCI sonothrombolysis has been shown to decrease infarct size and improve left ventricular (LV) systolic function in STEMI patients receiving urgent PCI. The aim of this study was to investigate whether post-PCI sonothrombolysis alone in STEMI patients with persistent ST elevation could reduce no-reflow and infarct size.
Methods:
Patients with STEMI with symptoms <12 hours who had persistent ST elevation (≤70% ST resolution) after primary PCI were randomized to sonothrombolysis or control. The primary end point was summed (Σ) ST elevation 60 minutes after study intervention. Secondary end points included infarct size, myocardial perfusion score, LV ejection fraction on cardiovascular magnetic resonance imaging at 2 months follow-up, and clinical outcome at 6-month follow-up.
Results:
Sixty-seven STEMI patients with persistent ST elevation after PCI were randomized (49 left anterior descending, 18 right coronary/left circumflex artery). No difference was observed in Σ ST elevation 60 minutes after study intervention (mean difference, 0.6 mm; 95% CI, -1.1 to 2.2, P = .50). Complete ST resolution occurred in 14 (40%) of patients treated with sonothrombolysis compared to 6 (19%) of controls (P = .16). Myocardial perfusion score index (1.5 ± 0.3 vs 1.5 ± 0.3, P = .93), infarct size (18.0% ± 10% vs 16.8% ± 11%; P = .29) and LV ejection fraction on cardiovascular magnetic resonance (46% ± 8% vs 47% ± 11% in the control group; P = .86) were comparable. Incidence of all-cause death, acute coronary syndrome, and hospital admission for heart failure at 6-month follow-up was similar between the groups (sonothrombolysis, 2; control, 5).
Conclusions:
In STEMI patients with persistent ST elevation after PCI, post-PCI sonothrombolysis did not result in more ST resolution or smaller infarct size compared to control subjects. The incidence of the combined clinical end points was remarkably low in this high-risk patient population.
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