Benefits of optimising coronary flow before stenting in primary percutaneous coronary intervention for ST-elevation myocardial infarction: insights from INFUSE-AMI

Aims: To determine the relation between thrombus aspiration (TA) and/or intra-lesion (IL) abciximab with pre-stent Thrombolysis In Myocardial Infarction (TIMI) flow grade and infarct size (IS) in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods and results: The INFUSE-AMI trial randomised 452 patients with anterior STEMI to IL abciximab vs. no abciximab, and to manual TA vs. no TA. The primary endpoint was cMRI-determined IS at 30 days. Patients were classified according to pre-stent TIMI flow. Complete data were available in 290 patients -68 (25.2%) with pre-stent TIMI 0/1 flow, 47 (17.4%) with TIMI 2 flow and 175 (57.4%) with TIMI 3 flow. Patients with pre-stent TIMI 3 flow had significantly lower IS (15.5% [4.6, 21.8] vs. 22.6% [14.7, 28.0] for TIMI 2 vs. 19.5 [14.4, 27.8] for TIMI 0/1, p<0.0001) and fewer 30-day clinical events (p=0.03). Patients receiving TA with or without IL abciximab had the highest rate of pre-stent TIMI 3 flow (p<0.0001) and patients receiving both had the smallest IS (14.7% vs. 17.3% for the other three groups, p=0.03). Conclusions: Optimisation of coronary flow prior to stent implantation may reduce infarct size and clinical events in STEMI patients undergoing primary PCI.