Stent thrombosis incidence in bare metal stents: Difference between revisions

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{{SI}}
__NOTOC__
{{WikiDoc Cardiology Network Infobox}}
{{Stent thrombosis}}
{{CMG}}
{{CMG}}; '''Associate Editors-In-Chief:''' Smita Kohli, M.D.; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.


'''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
==Overview==
Multiple contemporary studies involving  single center and multi center experience suggests an '''overall lifetime incidence of stent thrombosis is 0.5 % - 2.5 %'''.<ref name="pmid17662400">{{cite journal| author=Jensen LO, Maeng M, Kaltoft A, Thayssen P, Hansen HH, Bottcher M et al.| title=Stent thrombosis, myocardial infarction, and death after drug-eluting and bare-metal stent coronary interventions. | journal=J Am Coll Cardiol | year= 2007 | volume= 50 | issue= 5 | pages= 463-70 | pmid=17662400 | doi=10.1016/j.jacc.2007.06.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17662400  }} </ref> <ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref> <ref name="pmid15766835">{{cite journal| author=Moreno R, Fernández C, Hernández R, Alfonso F, Angiolillo DJ, Sabaté M et al.| title=Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 6 | pages= 954-9 | pmid=15766835 | doi=10.1016/j.jacc.2004.11.065 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15766835  }} </ref> <ref name="pmid11306525">{{cite journal| author=Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ et al.| title=Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. | journal=Circulation | year= 2001 | volume= 103 | issue= 15 | pages= 1967-71 | pmid=11306525 | doi= | pmc= | url= }} </ref><ref name="pmid11419889">{{cite journal| author=Schühlen H, Kastrati A, Pache J, Dirschinger J, Schömig A| title=Incidence of thrombotic occlusion and major adverse cardiac events between two and four weeks after coronary stent placement: analysis of 5,678 patients with a four-week ticlopidine regimen. | journal=J Am Coll Cardiol | year= 2001 | volume= 37 | issue= 8 | pages= 2066-73 | pmid=11419889 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11419889  }} </ref> There is some variation of these numbers with the definitions used. For instance, in a recent study of 8847 patients who received a [[BMS]], a cumulative incidence of definite, probable or possible [[stent thrombosis]] (ST) over 15 months was 2.15% and that for definite ST was 0.61%.<ref name="pmid17662400">{{cite journal| author=Jensen LO, Maeng M, Kaltoft A, Thayssen P, Hansen HH, Bottcher M et al.| title=Stent thrombosis, myocardial infarction, and death after drug-eluting and bare-metal stent coronary interventions. | journal=J Am Coll Cardiol | year= 2007 | volume= 50 | issue= 5 | pages= 463-70 | pmid=17662400 | doi=10.1016/j.jacc.2007.06.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17662400  }} </ref> In a study involving serial angiography after [[sirolimus]]-eluting stent (SES) and [[BMS]] implantation at 4, 11, and 21.2 ± 2.2 months, no [[BMS]] developed thrombus, however SES demonstrated the presence of thrombi and yellow plaques even as much as 2 years after implantation.<ref name="pmid17684153">{{cite journal| author=Awata M, Kotani J, Uematsu M, Morozumi T, Watanabe T, Onishi T et al.| title=Serial angioscopic evidence of incomplete neointimal coverage after sirolimus-eluting stent implantation: comparison with bare-metal stents. | journal=Circulation | year= 2007 | volume= 116 | issue= 8 | pages= 910-6 | pmid=17684153 | doi=10.1161/CIRCULATIONAHA.105.609057 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17684153  }} </ref>
==Incidence in Bare Metal Stents==
===Incidence of Early ST in BMS===


{{Editor Help}}
For purposes of discussion this group would include:
*'''Intra-procedural ST'''
*'''Acute ST:''' up to 24 hrs
*'''Subacute ST:''' 24 hrs to 30 days


Multiple contemporary studies involving  single center and multi center experience suggests an overall lifetime incidence of 0.5 % - 2.5 %.<ref name="pmid17662400">{{cite journal| author=Jensen LO, Maeng M, Kaltoft A, Thayssen P, Hansen HH, Bottcher M et al.| title=Stent thrombosis, myocardial infarction, and death after drug-eluting and bare-metal stent coronary interventions. | journal=J Am Coll Cardiol | year= 2007 | volume= 50 | issue= 5 | pages= 463-70 | pmid=17662400 | doi=10.1016/j.jacc.2007.06.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17662400  }} </ref><ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref><ref name="pmid15766835">{{cite journal| author=Moreno R, Fernández C, Hernández R, Alfonso F, Angiolillo DJ, Sabaté M et al.| title=Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 6 | pages= 954-9 | pmid=15766835 | doi=10.1016/j.jacc.2004.11.065 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15766835  }} </ref><ref name="pmid11306525">{{cite journal| author=Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ et al.| title=Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. | journal=Circulation | year= 2001 | volume= 103 | issue= 15 | pages= 1967-71 | pmid=11306525 | doi= | pmc= | url= }} </ref><ref name="pmid11419889">{{cite journal| author=Schühlen H, Kastrati A, Pache J, Dirschinger J, Schömig A| title=Incidence of thrombotic occlusion and major adverse cardiac events between two and four weeks after coronary stent placement: analysis of 5,678 patients with a four-week ticlopidine regimen. | journal=J Am Coll Cardiol | year= 2001 | volume= 37 | issue= 8 | pages= 2066-73 | pmid=11419889 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11419889  }} </ref> There is some variation of these numbers with the definitions used. For instance, in a recent study of 8847 patients who received a [[BMS]], a cumulative incidence of definite, probable or possible [[stent thrombosis]] (ST) over 15 months was 2.15% and that for definite ST was 0.61%.<ref name="pmid17662400">{{cite journal| author=Jensen LO, Maeng M, Kaltoft A, Thayssen P, Hansen HH, Bottcher M et al.| title=Stent thrombosis, myocardial infarction, and death after drug-eluting and bare-metal stent coronary interventions. | journal=J Am Coll Cardiol | year= 2007 | volume= 50 | issue= 5 | pages= 463-70 | pmid=17662400 | doi=10.1016/j.jacc.2007.06.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17662400  }} </ref> In a study involving serial angioscopy after sirolimus-eluting stent (SES) implantation at 4, 11, and 21.2 ±2.2 months no [[BMS]] had thrombus in 11 patients.<ref name="pmid17684153">{{cite journal| author=Awata M, Kotani J, Uematsu M, Morozumi T, Watanabe T, Onishi T et al.| title=Serial angioscopic evidence of incomplete neointimal coverage after sirolimus-eluting stent implantation: comparison with bare-metal stents. | journal=Circulation | year= 2007 | volume= 116 | issue= 8 | pages= 910-6 | pmid=17684153 | doi=10.1161/CIRCULATIONAHA.105.609057 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17684153 }} </ref>
====Supportive Trial Data====
*In study of 7484 patients with (intra vascular ultrasound study) [[IVUS]] before and after stenting, incidence of ST was 0.4% up to a week. The median time of ST was 24 hours and the minimum time was 1 hour.<ref name="pmid12821553">{{cite journal| author=Cheneau E, Leborgne L, Mintz GS, Kotani J, Pichard AD, Satler LF et al.| title=Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. | journal=Circulation | year= 2003 | volume= 108 | issue= 1 | pages= 43-7 | pmid=12821553 | doi=10.1161/01.CIR.0000078636.71728.40 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12821553 }} </ref>


==Incidence of early ST in BMS==
*In a retrospective analysis 4509 patients the rate of subacute ST was 0.51%.<ref name="pmid12427407">{{cite journal| author=Orford JL, Lennon R, Melby S, Fasseas P, Bell MR, Rihal CS et al.| title=Frequency and correlates of coronary stent thrombosis in the modern era: analysis of a single center registry. | journal=J Am Coll Cardiol | year= 2002 | volume= 40 | issue= 9 | pages= 1567-72 | pmid=12427407 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12427407  }} </ref>
*For purposes of discussion this group would include
====Higher Incidence of Subacute ST in Special Patient Populations====
**'''Intra-procedural ST'''
*In a group of 40 patients who underwent non cardiac surgery following [[BMS]], the incidence of ST while on two [[antiplatelet]] agents appeared to be 2.5 % (one patient out of 40).<ref name="pmid10758971">{{cite journal| author=Kałuza GL, Joseph J, Lee JR, Raizner ME, Raizner AE| title=Catastrophic outcomes of noncardiac surgery soon after coronary stenting. | journal=J Am Coll Cardiol | year= 2000 | volume= 35 | issue= 5 | pages= 1288-94 | pmid=10758971 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10758971  }} </ref>
**'''Acute ST:''' up to 24 hrs
*Incidence of ST in patients with [[acute coronary syndrome]](ACS) are higher than those with [[stable angina]] as demonstrated by ACUITY and TRITON-TIMI 38 trial databases.<ref name="pmid19171852">{{cite journal| author=Aoki J, Lansky AJ, Mehran R, Moses J, Bertrand ME, McLaurin BT et al.| title=Early stent thrombosis in patients with acute coronary syndromes treated with drug-eluting and bare metal stents: the Acute Catheterization and Urgent Intervention Triage Strategy trial. | journal=Circulation | year= 2009 | volume= 119 | issue= 5 | pages= 687-98 | pmid=19171852 | doi=10.1161/CIRCULATIONAHA.108.804203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19171852  }} </ref> <ref name="pmid19204315">{{cite journal| author=Cook S, Windecker S| title=Early stent thrombosis: past, present, and future. | journal=Circulation | year= 2009 | volume= 119 | issue= 5 | pages= 657-9 | pmid=19204315 | doi=10.1161/CIRCULATIONAHA.108.842757 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19204315  }} </ref>
**'''Subacute ST:''' 24 hrs to 30 days
*The incident rates of early ST in ACS i.e [[STEMI]] and [[NSTEMI]] have shown to be '''1.4 - 1.6%''', and '''0 - 2.9%''' respectively while ST incidence in patients with [[stable angina]] is '''0 - 0.5%'''.<ref name="pmid18377975">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP et al.| title=Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1353-63 | pmid=18377975 | doi=10.1016/S0140-6736(08)60422-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18377975  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783188 Review in: ACP J Club. 2008 Sep 16;149(3):12] </ref>
===Incidence of ST from 30 days up to 3 years or longer===
This would include:
*'''Late ST:''' 30 days to one year
*'''Very late ST:''' more than one year, but generally less than 3 years
*'''Later than 3 years'''


In study of 7484 patients with (intra vascular ultrasound study) [[IVUS]] before and after stenting, incidence of ST was 0.4% up to a week. The median time of ST was 24 hours and the minimum time was 1 hour.<ref name="pmid12821553">{{cite journal| author=Cheneau E, Leborgne L, Mintz GS, Kotani J, Pichard AD, Satler LF et al.| title=Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. | journal=Circulation | year= 2003 | volume= 108 | issue= 1 | pages= 43-7 | pmid=12821553 | doi=10.1161/01.CIR.0000078636.71728.40 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12821553  }} </ref>
The reported incidence in this group ranges between '''0-0.5%'''. Given the paucity of data only assumptions can be made for the group beyond 1-3 years.


In a retrospective analysis 4509 patients the rate of subacute ST was 0.51%.<ref name="pmid12427407">{{cite journal| author=Orford JL, Lennon R, Melby S, Fasseas P, Bell MR, Rihal CS et al.| title=Frequency and correlates of coronary stent thrombosis in the modern era: analysis of a single center registry. | journal=J Am Coll Cardiol | year= 2002 | volume= 40 | issue= 9 | pages= 1567-72 | pmid=12427407 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12427407  }} </ref>
====Incidence of Late-ST====


The incidence of subacute ST could be higher in special patient populations:
*The incidence of late ST with [[BMS]] was '''0.28%''' in a meta-analysis of 14 trials looking at 6675 patients.<ref name="pmid17145250">{{cite journal| author=Bavry AA, Kumbhani DJ, Helton TJ, Borek PP, Mood GR, Bhatt DL| title=Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials. | journal=Am J Med | year= 2006 | volume= 119 | issue= 12 | pages= 1056-61 | pmid=17145250 | doi=10.1016/j.amjmed.2006.01.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17145250 }} </ref>
*In a group of 40 patients who underwent non cardiac surgery following [[BMS]], the incidence of ST while on two antiplatelet agents appeared to be 2.5 % (one patient out of 40).<ref name="pmid10758971">{{cite journal| author=Kałuza GL, Joseph J, Lee JR, Raizner ME, Raizner AE| title=Catastrophic outcomes of noncardiac surgery soon after coronary stenting. | journal=J Am Coll Cardiol | year= 2000 | volume= 35 | issue= 5 | pages= 1288-94 | pmid=10758971 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10758971 }} </ref>


*Incidence of ST in patients with [[acute coronary syndrome]](ACS) are higher than those with stable angina as demonstrated by ACUITY AND TRITON-TIMI 38 trial databases.<ref name="pmid19171852">{{cite journal| author=Aoki J, Lansky AJ, Mehran R, Moses J, Bertrand ME, McLaurin BT et al.| title=Early stent thrombosis in patients with acute coronary syndromes treated with drug-eluting and bare metal stents: the Acute Catheterization and Urgent Intervention Triage Strategy trial. | journal=Circulation | year= 2009 | volume= 119 | issue= 5 | pages= 687-98 | pmid=19171852 | doi=10.1161/CIRCULATIONAHA.108.804203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19171852  }} </ref><ref name="pmid19204315">{{cite journal| author=Cook S, Windecker S| title=Early stent thrombosis: past, present, and future. | journal=Circulation | year= 2009 | volume= 119 | issue= 5 | pages= 657-9 | pmid=19204315 | doi=10.1161/CIRCULATIONAHA.108.842757 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19204315 }} </ref> The incident rates of early ST in [[ACS]] i.e [[STEMI]] and [[NSTEMI]] have shown to be 1.4-1.6%, and 0-2.9% respectively while ST incidence in patients with [[stable angina]] is 0-0.5%.<ref name="pmid18377975">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP et al.| title=Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1353-63 | pmid=18377975 | doi=10.1016/S0140-6736(08)60422-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18377975 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783188 Review in: ACP J Club. 2008 Sep 16;149(3):12] </ref>
*Long term [[aspirin]] therapy is necessary to reduce the incidence of late ST in patients with [[BMS]].<ref name="pmid8996288">{{cite journal| author=Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A| title=Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome. | journal=J Am Coll Cardiol | year= 1997 | volume= 29 | issue= 1 | pages= 6-12 | pmid=8996288 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8996288 }} </ref> <ref name="pmid15680728">{{cite journal| author=Ferrari E, Benhamou M, Cerboni P, Marcel B| title=Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 3 | pages= 456-9 | pmid=15680728 | doi=10.1016/j.jacc.2004.11.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15680728 }} </ref>


==Incidence of ST from 30 days up to 3 years or longer==
*Late ST is uncommon in patients who are on [[dual anti-platelet]] therapy(DAT).<ref name="pmid19371823">{{cite journal| author=van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ et al.| title=Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 16 | pages= 1399-409 | pmid=19371823 | doi=10.1016/j.jacc.2008.12.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19371823  }} </ref> <ref name="pmid15680728">{{cite journal| author=Ferrari E, Benhamou M, Cerboni P, Marcel B| title=Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 3 | pages= 456-9 | pmid=15680728 | doi=10.1016/j.jacc.2004.11.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15680728  }} </ref><ref name="pmid17349883">{{cite journal| author=Ellis SG, Colombo A, Grube E, Popma J, Koglin J, Dawkins KD et al.| title=Incidence, timing, and correlates of stent thrombosis with the polymeric paclitaxel drug-eluting stent: a TAXUS II, IV, V, and VI meta-analysis of 3,445 patients followed for up to 3 years. | journal=J Am Coll Cardiol | year= 2007 | volume= 49 | issue= 10 | pages= 1043-51 | pmid=17349883 | doi=10.1016/j.jacc.2007.01.015 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17349883  }} </ref>
*This would include
**'''Late ST:''' 30 days to one year
**'''Very late ST:''' more than one year, but generally less than 3 years
**'''Later than 3 years'''


The reported incidence in this group ranges between 0-0.5%. Given the paucity of data only assumptions can be made for the group beyond 1-3 years.
*With the use of second generation [[BMS]], and current antithrombotic regimens ([[aspirin]] and [[thienopyridine]]) the 30 days ST incidence range from '''0.5-2.5%''' in high risk patients.<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref> <ref name="pmid15766835">{{cite journal| author=Moreno R, Fernández C, Hernández R, Alfonso F, Angiolillo DJ, Sabaté M et al.| title=Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 6 | pages= 954-9 | pmid=15766835 | doi=10.1016/j.jacc.2004.11.065 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15766835  }} </ref> The incidence is higher if [[aspirin]] is used alone or when [[warfarin]] is used along with [[aspirin]] without [[thienopyridine]].<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref>
 
====Incidence of Very Late-ST====
The incidence of late ST with [[BMS]] was 0.28% in a meta-analysis of 14 trials looking at 6675 patients.<ref name="pmid17145250">{{cite journal| author=Bavry AA, Kumbhani DJ, Helton TJ, Borek PP, Mood GR, Bhatt DL| title=Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials. | journal=Am J Med | year= 2006 | volume= 119 | issue= 12 | pages= 1056-61 | pmid=17145250 | doi=10.1016/j.amjmed.2006.01.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17145250  }} </ref>
*It appears that ST in the very late group is exceedingly rare.  
 
*In a meta-analysis of 14 trials looking at 6675 patients no patient presented with very late ST of [[BMS]]. However regular follow up of most patients confined to one year or less.<ref name="pmid17145250">{{cite journal| author=Bavry AA, Kumbhani DJ, Helton TJ, Borek PP, Mood GR, Bhatt DL| title=Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials. | journal=Am J Med | year= 2006 | volume= 119 | issue= 12 | pages= 1056-61 | pmid=17145250 | doi=10.1016/j.amjmed.2006.01.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17145250  }} </ref>
Late ST is uncommon in patients who are on dual anti-platelet therapy(DAT).<ref name="pmid19371823">{{cite journal| author=van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ et al.| title=Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 16 | pages= 1399-409 | pmid=19371823 | doi=10.1016/j.jacc.2008.12.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19371823  }} </ref> <ref name="pmid15680728">{{cite journal| author=Ferrari E, Benhamou M, Cerboni P, Marcel B| title=Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 3 | pages= 456-9 | pmid=15680728 | doi=10.1016/j.jacc.2004.11.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15680728  }} </ref><ref name="pmid17349883">{{cite journal| author=Ellis SG, Colombo A, Grube E, Popma J, Koglin J, Dawkins KD et al.| title=Incidence, timing, and correlates of stent thrombosis with the polymeric paclitaxel drug-eluting stent: a TAXUS II, IV, V, and VI meta-analysis of 3,445 patients followed for up to 3 years. | journal=J Am Coll Cardiol | year= 2007 | volume= 49 | issue= 10 | pages= 1043-51 | pmid=17349883 | doi=10.1016/j.jacc.2007.01.015 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17349883  }} </ref>
 
Long term [[aspirin]] therapy is necessary to reduce the incidence of late ST in patients with [[BMS]].<ref name="pmid8996288">{{cite journal| author=Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A| title=Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome. | journal=J Am Coll Cardiol | year= 1997 | volume= 29 | issue= 1 | pages= 6-12 | pmid=8996288 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8996288  }} </ref> <ref name="pmid15680728">{{cite journal| author=Ferrari E, Benhamou M, Cerboni P, Marcel B| title=Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 3 | pages= 456-9 | pmid=15680728 | doi=10.1016/j.jacc.2004.11.041 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15680728  }} </ref>
 
With the use of second generation [[BMS]], and current antithrombotic regimens ([[aspirin]] and [[thienopyridine]]) the 30 days ST incidence range from 0.5-2.5% in high risk patients.<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref><ref name="pmid15766835">{{cite journal| author=Moreno R, Fernández C, Hernández R, Alfonso F, Angiolillo DJ, Sabaté M et al.| title=Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 6 | pages= 954-9 | pmid=15766835 | doi=10.1016/j.jacc.2004.11.065 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15766835  }} </ref> The incidence is higher if [[aspirin]] is used alone or when warfarin is used along with aspirin without thienopyridine.<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref>
 
It appears that ST in the very late group is exceedingly rare. In a meta-analysis of 14 trials looking at 6675 patients no patient presented with very late ST of [[BMS]]. However regular follow up of most patients confined to one year or less.<ref name="pmid17145250">{{cite journal| author=Bavry AA, Kumbhani DJ, Helton TJ, Borek PP, Mood GR, Bhatt DL| title=Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials. | journal=Am J Med | year= 2006 | volume= 119 | issue= 12 | pages= 1056-61 | pmid=17145250 | doi=10.1016/j.amjmed.2006.01.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17145250  }} </ref>


==References==
==References==
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Latest revision as of 21:11, 4 March 2013

Coronary stent thrombosis Microchapters

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Introduction

Definition

Epidemiology and Demographics

Relation to Bare Metal Stents
Relation to Drug Eluting Stents
Relation to Antiplatelet Medications

Pathophysiology

Risk Factors

Relationship to Discontinuation of Antiplatelet Therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Smita Kohli, M.D.; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Multiple contemporary studies involving single center and multi center experience suggests an overall lifetime incidence of stent thrombosis is 0.5 % - 2.5 %.[1] [2] [3] [4][5] There is some variation of these numbers with the definitions used. For instance, in a recent study of 8847 patients who received a BMS, a cumulative incidence of definite, probable or possible stent thrombosis (ST) over 15 months was 2.15% and that for definite ST was 0.61%.[1] In a study involving serial angiography after sirolimus-eluting stent (SES) and BMS implantation at 4, 11, and 21.2 ± 2.2 months, no BMS developed thrombus, however SES demonstrated the presence of thrombi and yellow plaques even as much as 2 years after implantation.[6]

Incidence in Bare Metal Stents

Incidence of Early ST in BMS

For purposes of discussion this group would include:

  • Intra-procedural ST
  • Acute ST: up to 24 hrs
  • Subacute ST: 24 hrs to 30 days

Supportive Trial Data

  • In study of 7484 patients with (intra vascular ultrasound study) IVUS before and after stenting, incidence of ST was 0.4% up to a week. The median time of ST was 24 hours and the minimum time was 1 hour.[7]
  • In a retrospective analysis 4509 patients the rate of subacute ST was 0.51%.[8]

Higher Incidence of Subacute ST in Special Patient Populations

  • In a group of 40 patients who underwent non cardiac surgery following BMS, the incidence of ST while on two antiplatelet agents appeared to be 2.5 % (one patient out of 40).[9]
  • Incidence of ST in patients with acute coronary syndrome(ACS) are higher than those with stable angina as demonstrated by ACUITY and TRITON-TIMI 38 trial databases.[10] [11]
  • The incident rates of early ST in ACS i.e STEMI and NSTEMI have shown to be 1.4 - 1.6%, and 0 - 2.9% respectively while ST incidence in patients with stable angina is 0 - 0.5%.[12]

Incidence of ST from 30 days up to 3 years or longer

This would include:

  • Late ST: 30 days to one year
  • Very late ST: more than one year, but generally less than 3 years
  • Later than 3 years

The reported incidence in this group ranges between 0-0.5%. Given the paucity of data only assumptions can be made for the group beyond 1-3 years.

Incidence of Late-ST

  • The incidence of late ST with BMS was 0.28% in a meta-analysis of 14 trials looking at 6675 patients.[13]
  • Long term aspirin therapy is necessary to reduce the incidence of late ST in patients with BMS.[14] [15]

Incidence of Very Late-ST

  • It appears that ST in the very late group is exceedingly rare.
  • In a meta-analysis of 14 trials looking at 6675 patients no patient presented with very late ST of BMS. However regular follow up of most patients confined to one year or less.[13]

References

  1. ↑ 1.0 1.1 Jensen LO, Maeng M, Kaltoft A, Thayssen P, Hansen HH, Bottcher M; et al. (2007). "Stent thrombosis, myocardial infarction, and death after drug-eluting and bare-metal stent coronary interventions". J Am Coll Cardiol. 50 (5): 463–70. doi:10.1016/j.jacc.2007.06.002. PMID 17662400.
  2. ↑ 2.0 2.1 2.2 Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK; et al. (1998). "A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators". N Engl J Med. 339 (23): 1665–71. doi:10.1056/NEJM199812033392303. PMID 9834303.
  3. ↑ 3.0 3.1 Moreno R, Fernández C, Hernández R, Alfonso F, Angiolillo DJ, Sabaté M; et al. (2005). "Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies". J Am Coll Cardiol. 45 (6): 954–9. doi:10.1016/j.jacc.2004.11.065. PMID 15766835.
  4. ↑ Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ; et al. (2001). "Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials". Circulation. 103 (15): 1967–71. PMID 11306525.
  5. ↑ Schühlen H, Kastrati A, Pache J, Dirschinger J, Schömig A (2001). "Incidence of thrombotic occlusion and major adverse cardiac events between two and four weeks after coronary stent placement: analysis of 5,678 patients with a four-week ticlopidine regimen". J Am Coll Cardiol. 37 (8): 2066–73. PMID 11419889.
  6. ↑ Awata M, Kotani J, Uematsu M, Morozumi T, Watanabe T, Onishi T; et al. (2007). "Serial angioscopic evidence of incomplete neointimal coverage after sirolimus-eluting stent implantation: comparison with bare-metal stents". Circulation. 116 (8): 910–6. doi:10.1161/CIRCULATIONAHA.105.609057. PMID 17684153.
  7. ↑ Cheneau E, Leborgne L, Mintz GS, Kotani J, Pichard AD, Satler LF; et al. (2003). "Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study". Circulation. 108 (1): 43–7. doi:10.1161/01.CIR.0000078636.71728.40. PMID 12821553.
  8. ↑ Orford JL, Lennon R, Melby S, Fasseas P, Bell MR, Rihal CS; et al. (2002). "Frequency and correlates of coronary stent thrombosis in the modern era: analysis of a single center registry". J Am Coll Cardiol. 40 (9): 1567–72. PMID 12427407.
  9. ↑ Kałuza GL, Joseph J, Lee JR, Raizner ME, Raizner AE (2000). "Catastrophic outcomes of noncardiac surgery soon after coronary stenting". J Am Coll Cardiol. 35 (5): 1288–94. PMID 10758971.
  10. ↑ Aoki J, Lansky AJ, Mehran R, Moses J, Bertrand ME, McLaurin BT; et al. (2009). "Early stent thrombosis in patients with acute coronary syndromes treated with drug-eluting and bare metal stents: the Acute Catheterization and Urgent Intervention Triage Strategy trial". Circulation. 119 (5): 687–98. doi:10.1161/CIRCULATIONAHA.108.804203. PMID 19171852.
  11. ↑ Cook S, Windecker S (2009). "Early stent thrombosis: past, present, and future". Circulation. 119 (5): 657–9. doi:10.1161/CIRCULATIONAHA.108.842757. PMID 19204315.
  12. ↑ Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP; et al. (2008). "Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial". Lancet. 371 (9621): 1353–63. doi:10.1016/S0140-6736(08)60422-5. PMID 18377975. Review in: ACP J Club. 2008 Sep 16;149(3):12
  13. ↑ 13.0 13.1 Bavry AA, Kumbhani DJ, Helton TJ, Borek PP, Mood GR, Bhatt DL (2006). "Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials". Am J Med. 119 (12): 1056–61. doi:10.1016/j.amjmed.2006.01.023. PMID 17145250.
  14. ↑ Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A (1997). "Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome". J Am Coll Cardiol. 29 (1): 6–12. PMID 8996288.
  15. ↑ 15.0 15.1 Ferrari E, Benhamou M, Cerboni P, Marcel B (2005). "Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis". J Am Coll Cardiol. 45 (3): 456–9. doi:10.1016/j.jacc.2004.11.041. PMID 15680728.
  16. ↑ van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ; et al. (2009). "Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry". J Am Coll Cardiol. 53 (16): 1399–409. doi:10.1016/j.jacc.2008.12.055. PMID 19371823.
  17. ↑ Ellis SG, Colombo A, Grube E, Popma J, Koglin J, Dawkins KD; et al. (2007). "Incidence, timing, and correlates of stent thrombosis with the polymeric paclitaxel drug-eluting stent: a TAXUS II, IV, V, and VI meta-analysis of 3,445 patients followed for up to 3 years". J Am Coll Cardiol. 49 (10): 1043–51. doi:10.1016/j.jacc.2007.01.015. PMID 17349883.


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