Manual thrombectomy with platelet glycoprotein IIb/IIIa blockade is associated with lower mortality in patients treated with primary PCI (9266 patients from the london heart attack group)

Abstract

Introduction: During Primary PCI (PPCI) for STEMI, both manual thrombectomy and GP IIb/IIIa antagonists have been shown to improve clinical outcomes but evidence is limited and inconsistent. We aimed to assess the impact of manual thrombectomy and GP IIb/IIIa use on mortality. Methods and results: This was an observational cohort study of 9,266 consecutive patients with STEMI treated with PPCI between 2007 and 2012 at 8 tertiary cardiac centres across London, UK. Outcome was assessed by all-cause mortality. Anonymous datasets from the 8 centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (IQR range: 1.2-4.6 years). Patients were split into 3 groups: those who underwent PCI using mechanical thrombectomy and GPIIb/IIIa inhibitors, those receiving either GP IIb/IIIa inhibitor or mechanical thrombectomy, and those receiving neither Of the 9266 consecutive STEMI patients presenting for PPCI, 2334 (25.2%) had both mechanical thrombectomy and adjunctive GP IIb/IIIa blockade, 5132 (55.4%) had either mechanical thrombectomy or GP IIb/IIIa blockade, 1800 (19.4%) had neither therapy. Patients who had both manual thrombectomy and GPIIb/IIIa blockade were significantly younger, more likely to be male, and had lower rates of diabetes, previous MI, previous PCI, renal failure and previous CVA. Patients receiving both therapies were also less likely to have been in cardiogenic shock, were more likely to receive a DES, have undergone the procedure via the radial access route and have a successful procedure (defined as TIMI 3 flow at the end of procedure). Kaplan-Meier estimates of mortality showed the lowest rates of events for those patients receiving both therapies, followed by those receiving a single therapy, with the highest rates of MACE in those receiving neither therapy (13.1% [95% CI 10.1-14.0] vs. 16.6% [95% CI 12.6-18.7] vs. 24.7% [20.1-29.4], p<0.0001). However, after multivariable adjustment, thrombectomy use with adjunctive GPIIb/IIIa was still associated with significantly decreased mortality rates when compared with those that had neither therapy (hazard ratio: 0.77, 95% confidence interval: 0.62-0.96, p = 0.02). Conclusion: Manual thrombectomy with adjunctive GPIIb/IIIa blockade appears to be offered to a lower risk cohort of patients than those receiving neither. After multivariate adjustment however, manual thrombectomy use with adjunctive GPIIb/IIIa blockade is still associated with improved outcome, in the form of decreased mortality, in this large observational cohort.