Can ischemic time predict the age of thrombus in ST elevation myocardial infarction?: an analysis from tertiary healthcare center in South India


  • Louie Fischer Department of Cardiology, MOSC Medical College Hospital, Kolenchery, Kerala, India
  • Elizabeth Joseph Department of Pathology, MOSC Medical College Hospital, Kolenchery, Kerala, India
  • Eapen Punnose Department of Pathology, MOSC Medical College Hospital, Kolenchery, Kerala, India
  • Anoop Mathew Department of Cardiology, MOSC Medical College Hospital, Kolenchery, Kerala, India
  • Sunitha Thomas Department of Pathology, MOSC Medical College Hospital, Kolenchery, Kerala, India
  • Ashish Indani SME, Medical writing, Tata Consultancy Services, Mumbai, Maharashtra, India
  • Poonam Bhutada Department of Research Methodology, Krishnamughda Institute of Advanced Learning and Research, India



Old thrombus, Primary PCI, Recent thrombus, STEMI, Thrombus histopathology, Thrombus disruption, Thrombus age


Background: ST Elevation myocardial infarction (STEMI) is characterized by plaque disruption with superimposed thrombus formation. However, studies from western population have suggested a delay between plaque disruption and the onset of symptoms. There is a paucity of Indian data on the relationship between ischemic time and the age of thrombus. Hence, we decided to study the histopathological characteristics of thrombus aspirated during primary percutaneous coronary intervention (PPCI) in patients of STEMI and its relation with the ischemic time.

Methods: 107 consecutive patients of STEMI undergoing PPCI with thrombus aspiration, mostly within 12 hours of symptom onset were included in this study. The aspirated thrombi were fixed in 10% formalin, processed and analysed by light microscopy. The thrombi were categorized as recent or lysed according to the histopathological characteristics.

Results: The mean age of the study population was 54.93 13.19 years. There were males 94 (87.85%) and 13(12.15%) were females. The culprit vessel was LAD in 36 (32.73%), RCA in 57 (51.82%) and LCX in 13 (11.82%). Left Main, Diagonal and OM were culprit vessels in one case (0.91%) each. Thrombus was identified in 102 (95.3%) out of 107 patients where as in five patients (4.7%) only plaque was seen. Histopathology revealed lysed thrombus in 68 (66.7%) of 102 patients, and recent thrombus in 34 (33.3%) patients.

Conclusions: In patients with STEMI, undergoing PPCI within 12 hours of symptom onset, majority of the thrombi were lysed indicative of a thrombus age of at least 24 hours. This suggests that plaque instability and thrombus formation frequently precedes the onset of symptoms. Hence, ischemic time cannot predict the age of thrombus in STEMI.


Van Der Wal AC, Becker AE. Atherosclerotic plaque rupture-pathologicbasis of plaque stability and instability. Cardiovasc Res. 1999;41:334-44.

Mann J, Davies MJ. Mechanisms of progression in native coronary artery disease: role of healed plaque disruption. Heart. 1999;82:265-8.

Henriques de GR, Van Der Wal AC, van der Loos CM, Becker AE. Sudden unexpected death in young adults. Discrepancies between initiation of acute plaque complications and the onset of acute coronary death. Eur Heart. 2002;J23:1433-40.

Burke AP, Kolodgie FD, Farb A, Weber DK, Malcom GT. Healed plaque ruptures and sudden coronary death: evidence that subclinical rupture has a role in plaque progression. Circulation. 2001;103:934-40.

Sianos G, Papafaklis MI, Daemen J, Vaina S, van Mieghem CA, van Domburg RT, et al. Angiographic stent thrombosis after routine use of drug-eluting stents in ST-segment elevation myocardial infarction: the importance of thrombus burden. J Am Coll Cardiol. 2007;50:573-83.

Napodano M, Ramondo A, Tarantini G, Peluso D, Compagno S, Fraccaro C, et al. Predictors and time-related impact of distal embolization during primary angioplasty. Eur Heart J. 2009;30:305-13.

Fokkema ML, Vlaar PJ, Svilaas T, Vogelzang M, Amo D, Diercks GF, et al. Incidence and clinical consequences of distal embolization on the coronary angiogram after percutaneous coronary intervention for STelevation myocardial infarction. Eur Heart J. 2009;30:908-15.

Sianos G, Papafaklis MI, Serruys PW. Angiographic thrombus burden classification in patients with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention. J Invasive Cardiol. 2010;22:6B-14B.

Singh M, Berger PB, Ting HH, Rihal CS, Wilson SH, Lennon RJ, et al. Influence of coronary thrombus on outcome of percutaneous coronary angioplasty in the current era (the Mayo Clinic experience). Am J Cardiol. 2001;88:1091-6.

Fukuda D, Tanaka A, Shimada K, Nishida Y, Kawarabayashi VS. Coronary thrombus in STEMI 388 June 26, 2014Volume 6Issue 6T, Yoshikawa J. Predicting angiographic distal embolization following percutaneous coronary intervention in patients with acute myocardial infarction. Am J Cardiol. 2003;91:403-7.

Iijima R, Shinji H, Ikeda N, Itaya H, Makino K, Funatsu A, et al. Comparison of coronary arterial finding by intravascular ultrasound in patients with “transient no-reflow” versus “reflow” during percutaneous coronary intervention in acute coronary syndrome. Am J Cardiol. 2006;97:29-33.

Rittersma SZ, Van Der Wal AC, Koch KT, Piek JJ, Henriques JP. Plaque instability frequently occurs days or weeks before occlusive coronary thrombosis: a pathological thrombectomy study in primary percutaneouscoronary intervention. Circulation. 2005;111:1160-5.

Kramer MC, van der Wal AC, Koch KT, Rittersma SZ, Li X. Histopathological Features of Aspirated Thrombi after Primary Percutaneous Coronary Intervention in Patients with ST-Elevation Myocardial Infarction. PLoS ONE. 2009;4(6):e5817.

Burke AP, Virmani R. Pathophysiology of acute myocardial infarction, Med Clin North Am. 2007;91(4):553-72.

Verouden NJ, Kramer MC, Li X, Meuwissen M, Koch KT, Henriques JP. Histopathology of aspirated thrombus and its association with ST-segment recovery in patients undergoing primary percutaneous coronary intervention with routine thrombus aspiration Catheter Cardio vascInterv. 2011;77(1):35-42.

Kolodgie FD, Virmani R, Burke AP, Farb A, Weber DK, Kutys R. Pathologic assessment of the vulnerable human coronary plaque Heart. 2004;90(12):1385-91.

Nakashima Y, Fujii H, Sumiyoshi S, Wight TN, Sueishi K. Early human atherosclerosis: accumulation of lipid and proteoglycans in intimal thickenings followed by macrophage infiltration, Arterioscler Thromb Vasc Biol. 2007;27(5):1159-65.

Goto S. Propagation of arterial thrombi: local and remote contributory factors Arterioscler Thromb Vasc Biol. 2004;24(12):2201-8.

Cambruzzi E, Canedo SJ, Budzyn RD, Mattos EI, Luiz de MeloBernardi G, Ioppi J, et al. Histopathological Evaluation of Coronary Thrombi in Patients with ST-Segment Elevation Myocardial Infarction, Revista Brasileira de Cardiologia Invasiva (English Edition). 2012;20(3):267-3.

Rittersma SZ, Van Der Wal AC, Koch KT. Plaque instability frequently occurs days or weeks before occlusive coronary thrombosis: a pathological thrombectomy study in primary percutaneous coronary intervention. Circulation. 2005;111:1160-5.

Sharma R, Bhairappa S, Prasad SR, Cholenahally NM. Clinical characteristics, angiographic profile and in hospital mortality in acute coronary syndrome patients in south Indian population, Heart India, Year. 2014;2(3):65-9.

Kramer MC, van der Wal AC, Koch KT, Ploegmakers JP, van der Schaaf RJ, Henriques JP. Presence of older thrombus is an independent predictor of long-term mortality in patients with ST-elevation myocardial infarction treated with thrombus aspiration during primary percutaneous coronary intervention Circulation. 2008;118(18):1810-6.

Beygui F, Collet JP, Nagaswami C, Weisel JW, Montalescot G. Mages in cardiovascular medicine Architecture of intracoronary thrombi in ST-elevation acute myocardial infarction: time makes the difference. Circulation. 2006;113(2):e21-3.

Vlaar PJ, Svilaas T, van der Horst IC, Diercks GFH, Fokkema ML, Smet BJGL. Cardiac death and reinfection after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study Lancet. 2008;371(9628):1915-20.

Luca G, Dudek D, Sardella G, Marino P, Chevalier B, Zijlstra F. Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized trials, Eur Heart J. 2008;29(24):3002-10.






Original Research Articles