The main principle of the preventive treatment for stent thrombosis is to perform the best PCI possible, including good expansion and apposition of the stent. In this context, the role of intravascular ultrasound has been studied extensively and can be helpful[1][2].
Combined antiplatelet therapy for the preventive treatment has been extensively studied and are routinely recommended.
In STARS trial[3], studying 1653 patients showed superiority of aspirin and ticlopidine over combination of aspirin and warfarin or aspirin alone for reducing subacute stent thrombosis, although there were more hemorrhagic complications than with aspirin alone.
A similar benefit for combined aspirin plus ticlopidine was noted in another randomized controlled trial[4].
Results from double blinded randomized studies- PCI-CURE trial[9], analyzing 2658 patients and CREDO trial[10], analyzing 2116 patients, revealed the benefit of clopidogrel therapy increased with time and provide evidence for at least one year therapy in patients with BMS. However both the studies did not evaluate DES.
TRITON TIMI-38[8]trial analyzing 12,844 patients who underwent stenting for ACS revealed intensive antiplatelet therapy with prasugrel resulted in fewer ischaemic outcomes including stent thrombosis than with standard clopidogrel.These findings were statistically robust irrespective of stent type, and the data affirm the importance of intensive platelet inhibition in patients with intracoronary stents.
The 2008 American College of Chest Physician illustrates the following guidelines for primary and secondary prevention of coronary artery disease[11].
“
1. For patients after myocardial infarction, after ACS, and those with stable CAD and patients
after percutaneous coronary intervention (PCI) with stent placed, we recommend daily aspirin (75–100 mg) as indefinite therapy. (Grade 1A).
2. For patients who undergo bare metal stent placement, we recommend the combination of aspirin and clopidogrel for at least 4 weeks (Grade 1A).
3. For patients undergoing PCI with BMS placement following ACS, we recommend 12 months of aspirin (75–100 mg/d) plus clopidogrel (75 mg/d) over aspirin alone (Grade 1A).
4. For patients undergoing PCI with a DES, we recommend aspirin (75–100 mg/d) plus clopidogrel (75 mg/d for at least 12 months) [Grade 1A for 3 to 4 months; Grade 1B for 4 to 12 months]. Beyond 1 year, we suggest continued treatment with aspirin plus clopidogrel indefinitely if no bleeding or other tolerability issues (Grade 2C).
↑Roy P, Steinberg DH, Sushinsky SJ; et al. (2008). "The potential clinical utility of intravascular ultrasound guidance in patients undergoing percutaneous coronary intervention with drug-eluting stents". Eur. Heart J. 29 (15): 1851–7. doi:10.1093/eurheartj/ehn249. PMID18550555. Unknown parameter |month= ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑Gerber R, Colombo A (2008). "Does IVUS guidance of coronary interventions affect outcome? a prime example of the failure of randomized clinical trials". Catheter Cardiovasc Interv. 71 (5): 646–54. doi:10.1002/ccd.21489. PMID18360858. Unknown parameter |month= ignored (help)
↑ 3.03.1Leon 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. PMID9834303.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑ 4.04.1Schömig A, Neumann FJ, Kastrati A, Schühlen H, Blasini R, Hadamitzky M; et al. (1996). "A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents". N Engl J Med. 334 (17): 1084–9. doi:10.1056/NEJM199604253341702. PMID8598866.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑Bertrand ME, Legrand V, Boland J, Fleck E, Bonnier J, Emmanuelson H; et al. (1998). "Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study". Circulation. 98 (16): 1597–603. PMID9778323.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑Urban P, Macaya C, Rupprecht HJ, Kiemeneij F, Emanuelsson H, Fontanelli A; et al. (1998). "Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS)". Circulation. 98 (20): 2126–32. PMID9815866.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑Bertrand ME, Rupprecht HJ, Urban P, Gershlick AH, CLASSICS Investigators (2000). "Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting : the clopidogrel aspirin stent international cooperative study (CLASSICS)". Circulation. 102 (6): 624–9. PMID10931801.CS1 maint: Multiple names: authors list (link)