Plaque rupture leads to a cascade of events culminating in collagen disruption, tissue factor release, platelet activation and thrombus formation. Pro-inflammatory conditions, hyperglycemia and smoking predispose to high thrombus burden (HTB) which is an independent predictor of slow or no-reflow. In patients with acute myocardial infarction (AMI), glycoprotein IIb/IIIa inhibitors (GPI) reduce thrombus burden and improve myocardial perfusion. These agents are typically administered systemically via the intravenous route or locally via an intracoronary (IC) route. However, as higher local concentrations of GPI are associated with enhanced platelet inhibition, intralesional (IL) GPI administration may be particularly effective in cases of HTB. Modest-sized randomized trials comparing IL and IC GPI delivery have reported conflicting outcomes. Some trials have demonstrated improved coronary flow and myocardial perfusion with reduced major adverse cardiac events with IL compared with IC GPI administration, whereas others have shown no significant benefits. Furthermore, although no direct comparison has been made between IL delivery using an aspiration catheter, microcatheter or a dedicated balloon-based “weeping” infusion-catheter, improved outcomes have been most consistent following GPI administration at the site of the lesion and thrombus with the dedicated infusion catheter. This review provides an update on the role and outcomes of IL GPI administration in patients with AMI and HTB. Based on the evidence we offer an algorithm demonstrating when to consider IL administration in patients with AMI undergoing intervention. We conclude with a perspective on the management of patients with STEMI and COVID-19 in whom a prothrombotic state often results in HTB.

中文翻译：

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急性心肌梗死病灶内递送糖蛋白 IIb/IIIa 抑制剂：回顾和建议

斑块破裂导致一系列事件，最终导致胶原蛋白破坏、组织因子释放、血小板活化和血栓形成。促炎状况、高血糖和吸烟易导致高血栓负荷 (HTB)，这是缓慢或无复流的独立预测因素。在急性心肌梗死 (AMI) 患者中，糖蛋白 IIb/IIIa 抑制剂 (GPI) 可降低血栓负荷并改善心肌灌注。这些药物通常通过静脉内途径全身给药或通过冠状动脉内 (IC) 途径局部给药。然而，由于较高的 GPI 局部浓度与增强的血小板抑制有关，因此病灶内 (IL) GPI 给药在 HTB 病例中可能特别有效。比较 IL 和 IC GPI 交付的中等规模的随机试验报告了相互矛盾的结果。一些试验表明，与 IC GPI 给药相比，IL 可改善冠状动脉血流和心肌灌注，减少主要心脏不良事件，而其他试验则没有显示出显着益处。此外，虽然没有直接比较使用抽吸导管、微导管或专用的基于球囊的“哭泣”输液导管的 IL 递送，但在病变和血栓部位施用 GPI 后，改善的结果最为一致。专用输液导管。本综述提供了 IL GPI 给药在 AMI 和 HTB 患者中的作用和结果的最新信息。基于证据，我们提供了一个算法，演示何时考虑对接受干预的 AMI 患者进行 IL 给药。