Stent thrombosis relation to antiplatelet medications: Difference between revisions

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{{Stent thrombosis}}
{{Stent thrombosis}}
{{CMG}}; '''Associate Editors-In-Chief:''' Smita Kohli, M.D.; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.  
{{CMG}}; '''Associate Editors-In-Chief:''' Smita Kohli, M.D.; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.  
 
==Relation to Antiplatelet Medications==
==Incidence of stent thrombosis while on dual antiplatelet therapy==
===Incidence of Stent Thrombosis While on Dual Antiplatelet Therapy===
 
====Supportive Trial Data: Incidence of Early ST====
'''Supportive trial data: Incidence of EARLY ST'''


This category would include the incidence of acute and subacute stent thrombosis.
This category would include the incidence of acute and subacute stent thrombosis.
*In a '''prospective observational cohort''' study of 2229 patients with [[DES]] ([[sirolimus]] or [[paclitaxel]])<ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref>, ST occurred in 1.3% with a 0.6% subacute ST  in patients who were on dual [[antiplatelet]] therapy.  
*In a '''prospective observational cohort''' study of 2229 patients with [[DES]] ([[sirolimus]] or [[paclitaxel]])<ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref>, ST occurred in 1.3% with a 0.6% subacute ST  in patients who were on dual [[antiplatelet]] therapy.  
*In a '''long-term follow-up''' study of 1911 patients with [[DES]] on dual [[antiplatelet]] therapy<ref name="pmid16860022">{{cite journal| author=Park DW, Park SW, Park KH, Lee BK, Kim YH, Lee CW et al.| title=Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. | journal=Am J Cardiol | year= 2006 | volume= 98 | issue= 3 | pages= 352-6 | pmid=16860022 | doi=10.1016/j.amjcard.2006.02.039 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16860022  }} </ref>, stent thrombosis occurred in 0.8% patients after [[DES]] implantation with 1.3%  stent thrombosis within 6 hours to 20.4 months. The incidence of ST was 3.3% in patients with complete discontinuation of antiplatelet therapy, 7.8% in patients with premature discontinuation and 0.6% in patients who did not discontinue antiplatelet therapy
*In a '''long-term follow-up''' study of 1911 patients with [[DES]] on dual [[antiplatelet]] therapy<ref name="pmid16860022">{{cite journal| author=Park DW, Park SW, Park KH, Lee BK, Kim YH, Lee CW et al.| title=Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. | journal=Am J Cardiol | year= 2006 | volume= 98 | issue= 3 | pages= 352-6 | pmid=16860022 | doi=10.1016/j.amjcard.2006.02.039 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16860022  }} </ref>, stent thrombosis occurred in 0.8% patients after [[DES]] implantation with 1.3%  stent thrombosis within 6 hours to 20.4 months. The incidence of ST was 3.3% in patients with complete discontinuation of antiplatelet therapy, 7.8% in patients with premature discontinuation and 0.6% in patients who did not discontinue antiplatelet therapy
*Results from an '''observational''' study involving 15157 patients with sirolimus-eluting stents ([[SES]]) <ref name="pmid16534015">{{cite journal| author=Urban P, Gershlick AH, Guagliumi G, Guyon P, Lotan C, Schofer J et al.| title=Safety of coronary sirolimus-eluting stents in daily clinical practice: one-year follow-up of the e-Cypher registry. | journal=Circulation | year= 2006 | volume= 113 | issue= 11 | pages= 1434-41 | pmid=16534015 | doi=10.1161/CIRCULATIONAHA.104.532242 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16534015  }} </ref>, reported that the rates of acute ST was 0.13% and subacute ST was 0.56%, representing a 12-month actuarial incidence of 0.87%. Thereby suggests a high degree of safety of [[SES]], with a rate of stent thrombosis similar to that observed in randomized trials.
*Results from an '''observational''' study involving 15157 patients with sirolimus-eluting stents ([[SES]]) <ref name="pmid16534015">{{cite journal| author=Urban P, Gershlick AH, Guagliumi G, Guyon P, Lotan C, Schofer J et al.| title=Safety of coronary sirolimus-eluting stents in daily clinical practice: one-year follow-up of the e-Cypher registry. | journal=Circulation | year= 2006 | volume= 113 | issue= 11 | pages= 1434-41 | pmid=16534015 | doi=10.1161/CIRCULATIONAHA.104.532242 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16534015  }} </ref>, reported that the rates of acute ST was 0.13% and subacute ST was 0.56%, representing a 12-month actuarial incidence of 0.87%. Thereby suggests a high degree of safety of [[SES]], with a rate of stent thrombosis similar to that observed in randomized trials.


 
====Supportive Trial Data: Incidence of Late ST====
'''Supportive trial data: Incidence of LATE ST'''
 
This category would include the incidence of late and very late stent thrombosis.
This category would include the incidence of late and very late stent thrombosis.


*In a '''cohort'''<ref name="pmid15963413">{{cite journal| author=Ong AT, McFadden EP, Regar E, de Jaegere PP, van Domburg RT, Serruys PW| title=Late angiographic stent thrombosis (LAST) events with drug-eluting stents. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 12 | pages= 2088-92 | pmid=15963413 | doi=10.1016/j.jacc.2005.02.086 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15963413  }} </ref> of 2006 patients with [[PES]] and [[SES]]  up to a mean follow-up of 15 months with a follow up rate of 98% of the patients, no ST occurred while patients were on dual [[antiplatelet]] therapy.
*In a '''cohort'''<ref name="pmid15963413">{{cite journal| author=Ong AT, McFadden EP, Regar E, de Jaegere PP, van Domburg RT, Serruys PW| title=Late angiographic stent thrombosis (LAST) events with drug-eluting stents. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 12 | pages= 2088-92 | pmid=15963413 | doi=10.1016/j.jacc.2005.02.086 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15963413  }} </ref> of 2006 patients with [[PES]] and [[SES]]  up to a mean follow-up of 15 months with a follow up rate of 98% of the patients, no ST occurred while patients were on dual [[antiplatelet]] therapy.
*In a '''long-term follow-up''' study of 1911 patients with [[DES]] on dual [[antiplatelet]] therapy<ref name="pmid16860022">{{cite journal| author=Park DW, Park SW, Park KH, Lee BK, Kim YH, Lee CW et al.| title=Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. | journal=Am J Cardiol | year= 2006 | volume= 98 | issue= 3 | pages= 352-6 | pmid=16860022 | doi=10.1016/j.amjcard.2006.02.039 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16860022  }} </ref>, ST occurred in 0.8% patients after [[DES]] with the 0.6%  of late stent thrombosis, which was similar to that for [[BMS]].


*In a '''long-term follow-up''' study of 1911 patients with [[DES]] on dual [[antiplatelet]] therapy<ref name="pmid16860022">{{cite journal| author=Park DW, Park SW, Park KH, Lee BK, Kim YH, Lee CW et al.| title=Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. | journal=Am J Cardiol | year= 2006 | volume= 98 | issue= 3 | pages= 352-6 | pmid=16860022 | doi=10.1016/j.amjcard.2006.02.039 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16860022  }} </ref>, ST occurred in 0.8% patients after [[DES]] with the 0.6%  of late stent thrombosis, which was similar to that for [[BMS]].
===Incidence of Stent Thrombosis while on Single Antiplatelet Therapy===
 
====Supportive Trial Data: Incidence of Early ST====
 
==Incidence of stent thrombosis while on single antiplatelet therapy==
 
'''Supportive trial data: Incidence of EARLY ST'''


This category would include acute and subacute ST while on single [[antiplatelet]] therapy.
This category would include acute and subacute ST while on single [[antiplatelet]] therapy.
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::*Another scenario is the patient who is intolerant to one antiplatelet medication. This again is a very uncommon situation, as hospitals use [[aspirin desensitization]].
::*Another scenario is the patient who is intolerant to one antiplatelet medication. This again is a very uncommon situation, as hospitals use [[aspirin desensitization]].


 
====Supportive Trial Data: Incidence of Late ST====
'''Supportive trial data: Incidence of LATE ST'''
 
This category would include late ST and very late ST.
This category would include late ST and very late ST.


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*In a study involving 1911 patients who had DES 0.15% of patients who presented with late ST were on one antiplatelet therapy. How ever it is not clear as to the number of patients in the whole cohort who were on single antiplatelet therapy<ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref>. In one study, hazard ratio for late ST on premature discontinuation of antiplatelet therapy was 57.13 (14.84 - 219.96) <ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref>.
*In a study involving 1911 patients who had DES 0.15% of patients who presented with late ST were on one antiplatelet therapy. How ever it is not clear as to the number of patients in the whole cohort who were on single antiplatelet therapy<ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref>. In one study, hazard ratio for late ST on premature discontinuation of antiplatelet therapy was 57.13 (14.84 - 219.96) <ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref>.


===Incidence of Stent Thrombosis with No Antiplatelet Therapy===
====Supportive Trial Data: Incidence of Early ST====
*This is an unlikely scenario in the current environment.
====Supportive trial data: Incidence of Late ST====
*On long term follow up to 19.4 months, 121 patients with [[DES]] had complete interruption of [[antiplatelet]] therapy with a ST rate of 3.3 % in that group. (this represented an overall risk of 0.2 % when applied to the whole study population.) In the same group the rate of ST when both antiplatelet therapies were stopped within 6 months of stent implantation was 9%<ref name="pmid16860022">{{cite journal| author=Park DW, Park SW, Park KH, Lee BK, Kim YH, Lee CW et al.| title=Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. | journal=Am J Cardiol | year= 2006 | volume= 98 | issue= 3 | pages= 352-6 | pmid=16860022 | doi=10.1016/j.amjcard.2006.02.039 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16860022  }} </ref>.


==Incidence of stent thrombosis with no antiplatelet therapy==
*Two patients presented with ST who were 343 and 335 days following [[DES]] implantation. They had ceased dual [[antiplatelet]] therapy within 14 days of ST . Data of other patients who had a DES with no antiplatelet cover for the same duration was not available<ref name="pmid15500897">{{cite journal| author=McFadden EP, Stabile E, Regar E, Cheneau E, Ong AT, Kinnaird T et al.| title=Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. | journal=Lancet | year= 2004 | volume= 364 | issue= 9444 | pages= 1519-21 | pmid=15500897 | doi=10.1016/S0140-6736(04)17275-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15500897  }} </ref>.


'''Supportive trial data: Incidence of EARLY ST'''
==2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention and 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)<ref name="pmid22070837">{{cite journal|author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions|journal=[[Journal of the American College of Cardiology]]|volume=58 |issue=24 |pages=2550–83|year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref><ref name="pmid22064599">{{cite journal| author=Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG et al.| title=2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2011 | volume=  | issue=  | pages=  | pmid=22064599 |doi=10.1161/CIR.0b013e31823c074e | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22064599  }} </ref>==
===Dual Antiplatelet Therapy Compliance and Stent Thrombosis (DO NOT EDIT) <ref name="pmid22070837">{{cite journal|author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]]|volume=58 |issue=24|pages=2550–83|year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref><ref name="pmid22064599">{{cite journal| author=Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG et al.| title=2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2011 | volume=  | issue=  | pages=  | pmid=22064599 |doi=10.1161/CIR.0b013e31823c074e | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22064599  }} </ref>===


*This is an unlikely scenario in the current environment.
{|class="wikitable"


|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)


'''Supportive trial data: Incidence of LATE ST'''
|-
 
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' PCI with coronary stenting ([[BMS]] or [[DES]]) should not be performed if the patient is not likely to be able to tolerate and comply with [[dual antiplatelet therapy]] (DAPT) for the appropriate duration of treatment based on the type of [[stent]] implanted.<ref>Grines CL, Bonow RO, Casey DE Jr., et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol. 2007; 49: 734– 9. </ref><ref>Leon MB, Baim DS, Popma JJ, et al., Stent Anticoagulation Restenosis Study Investigators. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. N Engl J Med. 1998; 339: 1665–71.</ref><ref>Mauri L, Hsieh WH, Massaro JM, et al. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med. 2007; 356: 1020– 9.</ref><ref> McFadden EP, Stabile E, Regar E, et al. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet. 2004; 364: 1519– 21.</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*On long term follow up to 19.4 months, 121 patients with [[DES]] had complete interruption of [[antiplatelet]] therapy with a ST rate of 3.3 % in that group. (this represented an overall risk of 0.2 % when applied to the whole study population.) In the same group the rate of ST when both antiplatelet therapies were stopped within 6 months of stent implantation was 9%<ref name="pmid16860022">{{cite journal| author=Park DW, Park SW, Park KH, Lee BK, Kim YH, Lee CW et al.| title=Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. | journal=Am J Cardiol | year= 2006 | volume= 98 | issue= 3 | pages= 352-6 | pmid=16860022 | doi=10.1016/j.amjcard.2006.02.039 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16860022  }} </ref>.
 
*Two patients presented with ST who were 343 and 335 days following [[DES]] implantation. They had ceased dual [[antiplatelet]] therapy within 14 days of ST . Data of other patients who had a DES with no antiplatelet cover for the same duration was not available<ref name="pmid15500897">{{cite journal| author=McFadden EP, Stabile E, Regar E, Cheneau E, Ong AT, Kinnaird T et al.| title=Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. | journal=Lancet | year= 2004 | volume= 364 | issue= 9444 | pages= 1519-21 | pmid=15500897 | doi=10.1016/S0140-6736(04)17275-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15500897  }} </ref>.


|}


==References==
==References==
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[[Category: Cardiology]]
[[Category: Cardiology]]
[[Category: Emergency medicine]]
[[Category: Emergency medicine]]
[[Category:Needs overview]]


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Latest revision as of 21:28, 4 March 2013

Coronary stent thrombosis Microchapters

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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.

Relation to Antiplatelet Medications

Incidence of Stent Thrombosis While on Dual Antiplatelet Therapy

Supportive Trial Data: Incidence of Early ST

This category would include the incidence of acute and subacute stent thrombosis.

  • In a prospective observational cohort study of 2229 patients with DES (sirolimus or paclitaxel)[1], ST occurred in 1.3% with a 0.6% subacute ST in patients who were on dual antiplatelet therapy.
  • In a long-term follow-up study of 1911 patients with DES on dual antiplatelet therapy[2], stent thrombosis occurred in 0.8% patients after DES implantation with 1.3% stent thrombosis within 6 hours to 20.4 months. The incidence of ST was 3.3% in patients with complete discontinuation of antiplatelet therapy, 7.8% in patients with premature discontinuation and 0.6% in patients who did not discontinue antiplatelet therapy
  • Results from an observational study involving 15157 patients with sirolimus-eluting stents (SES) [3], reported that the rates of acute ST was 0.13% and subacute ST was 0.56%, representing a 12-month actuarial incidence of 0.87%. Thereby suggests a high degree of safety of SES, with a rate of stent thrombosis similar to that observed in randomized trials.

Supportive Trial Data: Incidence of Late ST

This category would include the incidence of late and very late stent thrombosis.

  • In a cohort[4] of 2006 patients with PES and SES up to a mean follow-up of 15 months with a follow up rate of 98% of the patients, no ST occurred while patients were on dual antiplatelet therapy.
  • In a long-term follow-up study of 1911 patients with DES on dual antiplatelet therapy[2], ST occurred in 0.8% patients after DES with the 0.6% of late stent thrombosis, which was similar to that for BMS.

Incidence of Stent Thrombosis while on Single Antiplatelet Therapy

Supportive Trial Data: Incidence of Early ST

This category would include acute and subacute ST while on single antiplatelet therapy.

  • This is an uncommon category as most patients are on dual antiplatelet medications.How ever it has been suggested that those patients who:
  • suboptimally loaded with dual antiplatelet therapy,
  • receive bivalirudin, may be at an increased risk of ST during the waning of the effect of bivalirudin and
  • during the time period until dual antiplatelet effects becomes adequate.
  • Another scenario is the patient who is intolerant to one antiplatelet medication. This again is a very uncommon situation, as hospitals use aspirin desensitization.

Supportive Trial Data: Incidence of Late ST

This category would include late ST and very late ST.

  • Overall the incidence of late ST in patients who presented on aspirin monotherapy was 0.25%. How ever no data was reported as to the proportion of patients who were on aspirin monotherpay at that time. 60% of the patients who presented with late ST and were on aspirin monotherpay after 6 months of the procedure. It is possible that the majority of the patients may have been on aspirin monotherapy at that time, yielding an incidence of ST for this group of 0.25%[1].
  • In a study involving 1911 patients who had DES 0.15% of patients who presented with late ST were on one antiplatelet therapy. How ever it is not clear as to the number of patients in the whole cohort who were on single antiplatelet therapy[1]. In one study, hazard ratio for late ST on premature discontinuation of antiplatelet therapy was 57.13 (14.84 - 219.96) [1].

Incidence of Stent Thrombosis with No Antiplatelet Therapy

Supportive Trial Data: Incidence of Early ST

  • This is an unlikely scenario in the current environment.

Supportive trial data: Incidence of Late ST

  • On long term follow up to 19.4 months, 121 patients with DES had complete interruption of antiplatelet therapy with a ST rate of 3.3 % in that group. (this represented an overall risk of 0.2 % when applied to the whole study population.) In the same group the rate of ST when both antiplatelet therapies were stopped within 6 months of stent implantation was 9%[2].
  • Two patients presented with ST who were 343 and 335 days following DES implantation. They had ceased dual antiplatelet therapy within 14 days of ST . Data of other patients who had a DES with no antiplatelet cover for the same duration was not available[5].

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention and 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery (DO NOT EDIT)[6][7]

Dual Antiplatelet Therapy Compliance and Stent Thrombosis (DO NOT EDIT) [6][7]

Class III (Harm)
"1. PCI with coronary stenting (BMS or DES) should not be performed if the patient is not likely to be able to tolerate and comply with dual antiplatelet therapy (DAPT) for the appropriate duration of treatment based on the type of stent implanted.[8][9][10][11] (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 1.2 1.3 Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G; et al. (2005). "Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents". JAMA. 293 (17): 2126–30. doi:10.1001/jama.293.17.2126. PMID 15870416.
  2. ↑ 2.0 2.1 2.2 Park DW, Park SW, Park KH, Lee BK, Kim YH, Lee CW; et al. (2006). "Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up". Am J Cardiol. 98 (3): 352–6. doi:10.1016/j.amjcard.2006.02.039. PMID 16860022.
  3. ↑ Urban P, Gershlick AH, Guagliumi G, Guyon P, Lotan C, Schofer J; et al. (2006). "Safety of coronary sirolimus-eluting stents in daily clinical practice: one-year follow-up of the e-Cypher registry". Circulation. 113 (11): 1434–41. doi:10.1161/CIRCULATIONAHA.104.532242. PMID 16534015.
  4. ↑ Ong AT, McFadden EP, Regar E, de Jaegere PP, van Domburg RT, Serruys PW (2005). "Late angiographic stent thrombosis (LAST) events with drug-eluting stents". J Am Coll Cardiol. 45 (12): 2088–92. doi:10.1016/j.jacc.2005.02.086. PMID 15963413.
  5. ↑ McFadden EP, Stabile E, Regar E, Cheneau E, Ong AT, Kinnaird T; et al. (2004). "Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy". Lancet. 364 (9444): 1519–21. doi:10.1016/S0140-6736(04)17275-9. PMID 15500897.
  6. ↑ 6.0 6.1 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter |month= ignored (help)
  7. ↑ 7.0 7.1 Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31823c074e. PMID 22064599.
  8. ↑ Grines CL, Bonow RO, Casey DE Jr., et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol. 2007; 49: 734– 9.
  9. ↑ Leon MB, Baim DS, Popma JJ, et al., Stent Anticoagulation Restenosis Study Investigators. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. N Engl J Med. 1998; 339: 1665–71.
  10. ↑ Mauri L, Hsieh WH, Massaro JM, et al. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med. 2007; 356: 1020– 9.
  11. ↑ McFadden EP, Stabile E, Regar E, et al. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet. 2004; 364: 1519– 21.

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