Stent thrombosis prevention

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

Treatment

Complications

Prevention

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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[edit | edit source]

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.

* There are better outcomes noted with the use of aspirin plus ticlopidine or clopidogrel than with aspirin plus warfarin or aspirin alone[3][4][5][6][7].
* Preliminary evidence suggests prasugrel resulted in fewer ischaemic outcomes including stent thrombosis than with standard clopidogrel[8].

## Clinical Trial Data[edit | edit source]

* 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.

## Guidelines for Prevention[edit | edit source]

The 2008 American College of Chest Physician illustrates the following guidelines for primary and secondary prevention of coronary artery disease[11].

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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).

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## References[edit | edit source]

1. ↑ 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. PMID 18550555. Unknown parameter `|month=` ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
2. ↑ 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. PMID 18360858. Unknown parameter `|month=` ignored (help)
3. ↑ 3.0 3.1 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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
4. ↑ 4.0 4.1 Schömig 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. PMID 8598866.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ 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. PMID 9778323.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
6. ↑ 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. PMID 9815866.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
7. ↑ 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. PMID 10931801.CS1 maint: Multiple names: authors list (link)
8. ↑ 8.0 8.1 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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)  Review in: ACP J Club. 2008 Sep 16;149(3):12
9. ↑ Mehta SR, Yusuf S, Peters RJ, Bertrand ME, Lewis BS, Natarajan MK; et al. (2001). "Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study". Lancet. 358 (9281): 527–33. PMID 11520521.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
10. ↑ Steinhubl SR, Berger PB, Mann JT, Fry ET, DeLago A, Wilmer C; et al. (2002). "Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial". JAMA. 288 (19): 2411–20. PMID 12435254.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)  Review in: ACP J Club. 2003 Jul-Aug;139(1):2
11. ↑ Becker RC, Meade TW, Berger PB, Ezekowitz M, O'Connor CM, Vorchheimer DA; et al. (2008). "The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 776S–814S. doi:10.1378/chest.08-0685. PMID 18574278.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)

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