Advanced Strategies in AMI Management: Overcoming High Thrombus Burden Challenges

Acute myocardial infarction (AMI) presents a significant clinical challenge, especially in cases complicated by high thrombus burden, balancing the mandate for rapid reperfusion with the hazards of distal embolization and no-reflow. Emerging imaging and pharmacologic strategies are reshaping how clinicians manage these complex cases.

Intravascular imaging technologies, such as IVUS and OCT, may improve decision-making by providing detailed visualization of thrombus burden, and guidelines endorse their use to optimize PCI in complex lesions; however, evidence for outcome improvement specifically in high thrombus burden remains heterogeneous.

These technologies enhance decision-making during percutaneous coronary intervention and have been associated in some studies with lower adverse events; however, data are heterogeneous and include nonrandomized designs, as discussed in a recent systematic review.

Building on imaging-informed decision-making, these modalities also guide effective interventions. Techniques like thrombus aspiration and deferred stenting may have a role in selective or bailout use for high thrombus burden, aiming to minimize distal embolization and improve myocardial perfusion. Guidelines support imaging to optimize PCI in complex lesions, while large RCTs have not shown mortality benefit for routine aspiration.

Selective thrombectomy or plaque modification in high thrombus burden lesions aims to mitigate immediate procedural complications; longer-term cardiac function is more directly influenced by comprehensive secondary prevention and heart failure therapies when indicated.

In chronic HFrEF, sacubitril/valsartan improves outcomes; in the immediate post-AMI setting without established HFrEF, evidence is mixed (PARADISE-MI neutral), and guidelines do not recommend routine initiation.

Meta-analyses on ARNI therapy suggest potential benefits in selected post-AMI patients with reduced ejection fraction, but guidelines have not adopted routine initiation in this setting.

For high-risk chronic HFrEF after recent decompensation, vericiguat reduced the composite of cardiovascular death or heart failure hospitalization; its role is in selected patients who develop chronic HFrEF after AMI, not routine post-AMI care.

The VICTORIA trial showed a reduction in the composite of cardiovascular death or heart failure hospitalization in high-risk chronic HFrEF; this was not a study limited to post-AMI patients, and its implications pertain to those who subsequently develop chronic HFrEF after AMI rather than routine post-AMI use.

Building on imaging-informed acute PCI strategies, longer-term management targets patients who progress to chronic HFrEF after AMI.

For patients experiencing severe clinical challenges, combining imaging guidance with tailored pharmacotherapy can pivot treatment trajectories toward improved outcomes.

From IVUS/OCT-guided PCI and selective thrombus management in high-burden lesions to targeted heart failure therapies for those who progress to chronic HFrEF, clinicians have a growing—yet nuanced—toolkit to improve care.

Key Takeaways:

• Advanced imaging techniques like IVUS and OCT can improve procedural guidance and may be associated with better outcomes, particularly when used to clarify lesion morphology in complex or high thrombus burden cases.
• Selective thrombus management strategies may reduce distal embolization in high thrombus burden, though large RCTs did not show a mortality benefit and raised potential stroke concerns.
• ARNI therapy, notably sacubitril/valsartan, may improve biomarkers or remodeling in select post-AMI patients, but guidelines primarily recommend its use for chronic HFrEF rather than routine immediate post-AMI initiation.
• Vericiguat reduced the composite of cardiovascular death or heart failure hospitalization in high-risk chronic HFrEF and may have a role in selected patients who develop HFrEF after AMI.