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Manual Clot Removal After Heart Attack May Not Help, Could Harm


5 Star

Manual Clot Removal After Heart Attack May Not Help, Could Harm

Our Review Summary

Removing clots during angioplasty to open up a blocked coronary artery has become a common practice.  This study of a large number of randomly selected patients showed that there was little difference between those patients who had only angioplasty and those who had angioplasty and manual removal of blood clots with respect to major cardiac problems (cardiovascular death, recurrent heart attack, cardiac shock, or heart failure) in the six-months after treatment.  Both outcomes were essentially the same.  However, there was an increase in strokes in the 30 days after treatment in patients who had their clots manually removed along with the angioplasty.

The story does a fine job of communicating the major findings of the study and meets the standard on most of our criteria. Apart from some discussion of cost, the main item on our wish list would be more thoughtful evaluation from an independent expert. Although an outside expert is quoted, he doesn’t do much more than affirm that the findings are important. Just how important are they and what should the patient — the target of this story — do with this information?


Why This Matters

Angioplasty is common after a cardiac event and manual clot removal is considered routine practice.  If this practice has no practical clinical value and has negative implications for strokes within 30 days after treatment, then perhaps this routine practice should be re-evaluated.  Even if the increase in strokes is small, the fact that clot removal appears to have no benefit, but would take longer and incur more cost, make it appear unnecessary.


Does the story adequately discuss the costs of the intervention?

Not Satisfactory

The story does not discuss the cost of angioplasty, or whether that cost would be affected if routine practice regarding clot removal is changed. While there are many ways that costs might change that would be difficult or impossible to predict (for example, the impact of differing stroke rates and the related follow-up care), it should have been possible to estimate the direct costs of the procedure with or without clot removal.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?


The story reports the absolute difference in the primary composite outcome in the two groups in this study (in fact there was no difference between those groups, indicating no added benefit for clot removal), which earns the story a satisfactory rating here.

With that being said, the general benefits of angioplasty are not really discussed in the story. The assumption made is that after a heart attack, where clogged arteries occur, angioplasty is an accepted and effective treatment.  A bit of background on angioplasty as a treatment and stent placement might have filled out this story and made it clearer why these two approaches were being evaluated in the first place.

Does the story adequately explain/quantify the harms of the intervention?


The story clearly states that there is no apparent benefit for clot removal and that there is some increased occurrence of strokes with the procedure. The absolute percentage of subjects who had a stroke in each group is also provided, so readers get a very clear picture of how often this occurs and the difference between the groups.

Does the story seem to grasp the quality of the evidence?


The story reports that this was a large randomized trial done by a team who has been doing research in this area. It quotes an expert who says that this has been an “eagerly awaited trial” that “will likely have important implications for clinical practice.” So there’s enough information here to discern that this was a well-conducted study that produced meaningful results, and we’ll award the story a Satisfactory rating on that basis. However, we wish the story had pushed just a bit harder as to what the “important implications” of this study will likely be. It seems that there’s a lot of conflicting data in this area, and it’s not clear from the story how the results may change practice — and that’s perspective that readers would like to have.

Does the story commit disease-mongering?


There was no disease mongering in this story.  Heart attacks occur and need to be treated, and this story presents a view on what the best treatment might be.

Does the story use independent sources and identify conflicts of interest?


The information was released simultaneously in the New England Journal of Medicine and presented at a conference. The story references data from the study and quotes an expert who was not affiliated with the study. While the story meets our standard, we wish that the independent expert had been pressed for a more meaningful evaluation, as discussed above.

Does the story compare the new approach with existing alternatives?


The alternative here is clearly to do the angioplasty without clot removal. That is satisfactorily established. We wish the story had been a bit clearer about the different techniques available for clot removal, however. The story talks about “manual” vs. “mechanical” removal, but never explains what that means. The press release notes that with “manual” clot removal,”the surgeon uses a syringe to create suction to remove clots,” whereas mechanical removal “uses machinery to create the suction.”

Does the story establish the availability of the treatment/test/product/procedure?


The story does not mention the availability of either of these procedures, but assumes that both are readily available and widespread. That’s accurate.

Does the story establish the true novelty of the approach?


The story makes clear that there was prior research on this topic showing benefit from clot removal.

Does the story appear to rely solely or largely on a news release?


While there is a press release on this study produced by the conference, the expert interviews are evidence that the story did not rely on them excessively. We’d note that there is some information in the press release that would have made the story better.

Total Score: 9 of 10 Satisfactory


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