Prognostic significance of coronary thrombus in patients undergoing percutaneous coronary intervention for acute coronary syndromes: a subanalysis of the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial

Abstract

Objectives: The objective of this study is to investigate the incidence and clinical implications of thrombus on baseline angiography among patients presenting with non-ST-segment elevation acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI).

Background: Given current advances in the pharmacological and mechanical treatment of ACS patients managed with an early invasive strategy, the incidence and prognostic importance of pre-procedural lesion thrombus is warranted.

Methods: In the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial, a total of 3,627 patients with moderate- and high-risk ACS undergoing PCI had their baseline and final post-PCI angiograms analyzed by an independent angiographic core laboratory.

Results: Patients with thrombus (n = 530 [15%]) compared with those without thrombus had higher rates of impaired final epicardial coronary flow (final Thrombolysis In Myocardial Infarction [TIMI] flow grade 3: 89.6% vs. 97.1%, p < 0.0001). Thrombus was an independent predictor of 30 day death (odds ratio [OR]: 3.16 [95% confidence interval (CI): 1.20 to 8.37], p = 0.02), and myocardial infarction (MI) at 30 days (OR: 1.62 [95% CI: 1.17 to 2.24], p = 0.003) and at 1 year (OR: 1.56 [95% CI: 1.16 to 2.08], p = 0.003). Patients with thrombus had significantly higher rates of stent thrombosis (ST) compared with patients without thrombus at 30 days (2.8% vs. 1.1%, p = 0.002) and at 1 year (3.7% vs. 1.8%, p = 0.003), and thrombus was an independent predictor of ST at both 30 days (OR: 2.61 [95% CI: 1.38 to 4.91]) and 1 year (OR: 2.98 [95% CI: 1.64 to 5.42]).

Conclusions: Pre-procedural thrombus was present in 15% of moderate- and high-risk ACS patients undergoing PCI in the ACUITY trial. Baseline thrombus predicts increased ischemic complications at 30 days including a 3-fold increased risk of death as well as MI up to 1 year. Further evaluation of adjunctive pharmacotherapy is needed in this high-risk population.