Stent Thrombosis Risk and Management

The Big Heart Disease Lie

Latest Treatments for Heart Disease

Get Instant Access

Several large-scale studies of the carefully selected patients from randomized trials or more general practice36,37 have attempted to assess the incidence, timing, and risk factors for DES-associated stent thrombosis. Intravascular ultrasound (IVUS) and autopsy studies suggest a correlation with stent under-expansion, dissection, plaque prolapse, and stenting adjacent to vulnerable plaque.38 The 30-day risk appears to be 0.6% to 1.4%, which is not dissimilar to that with bare metal stents. From 6 months to 2 years, however, some studies suggest numerically small but significant excess risk with DESs. Simoli-mus- and paclitaxel-eluting stents appear to have similar risks.30 Consistent findings among the studies are the relation of cessation of clopidogrel therapy, renal failure, and bifurcation lesions to risk of thrombosis, often increasing the risk by more than five times.36,37 Other studies have found that the thrombosis risk also was related to stent length, in-stent

100-

— Bare metal stent

Time after initial procedure (months)

100-

— Bare metal stent

so s6

Time after initial procedure (months)

RAVEL, SIRIUS, E-SIRIUS S C-SIRIUS

— Bare metal stent

Time after initial procedure (months)

Bare metal stent Taxus s6

Time after initial procedure (months)

After 12 mos: 4 vs 0

— Bare metal stent

24 30

Time after initial procedure (months)

— Bare metal stent

so s6

Time after initial procedure (months)

— Bare metal stent

Time after initial procedure (months)

— Bare metal stent

Time after initial procedure (months)

Figure 15-11. Long-term clinical outcomes from the initial randomized studies of the Cypher and Taxus stents compared with bare metal stents. A, Freedom from cardiac death. B, Freedom from myocardial infarction. C, Freedom from stent thrombosis. D, Freedom from target lesion revascularization.

restenosis treatment, diabetes, and low ejection fraction, albeit at a lesser magnitude of risk. Stent thrombosis is poorly responsive to fibrinolytic therapy and usually results in myocardial infarction, and because stents are typically placed in large proximal vessels, the result is death in 15% to 48% of cases.36,37

Thrombosis should be managed with emergency angioplasty, with aggressive platelet antagonist use, and with IVUS if a mechanical cause is suspected; if there is no obvious mechanical cause and the patient has been taking dual-antiplatelet therapy, further coagulation testing should be performed.38,39 Late stent thrombosis especially has been related to cessation of dual-antiplatelet therapy in conjunction with hypercoagulative risk of major surgery.40,41 A DES should be considered contraindicated if surgery that cannot be performed on aspirin is anticipated within approximately 2 years. Although the approach is not yet validated, I suggest aspirin and clopidogrel resistance testing for patients with risk factors before using DESs in the elective setting.38,39

Was this article helpful?

0 0
Your Heart and Nutrition

Your Heart and Nutrition

Prevention is better than a cure. Learn how to cherish your heart by taking the necessary means to keep it pumping healthily and steadily through your life.

Get My Free Ebook


Post a comment