Log in to MyACC
Stent Thrombosis Risk Based on Clinical Presentation and Platelet Reactivity
Quick Takes
- There is a gradient of stent thrombosis (ST) risk after PCI based on the initial acuity of clinical presentation, ranging from STEMI (highest ST risk) to NSTEMI to UA to non-ACS (lowest ST risk).
- The increased risk of ST in ACS patients was greatest in the first 30 days after PCI and this increased risk of early ST was largely confined to patients with increased high platelet reactivity on clopidogrel.
- These data underscore the importance of adequate P2Y12 inhibition after MI, especially within the first 30 days after stent implantation, preferably with the use of newer potent P2Y12 inhibitors.
Study Questions:
What is the risk period for increased stent thrombosis (ST) post–percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS), and is this increased risk related to high platelet reactivity (HPR)?
Methods:
The investigators using the ADAPT-DES registry, compared ST rates during 2-year follow-up post-PCI with drug-eluting stents (DES) among patients presenting with ACS (myocardial infarction [MI] or unstable angina [UA]) and non-ACS. Landmark analyses were done at 30 days and 1 year post-PCI. Platelet reactivity on aspirin and clopidogrel post-PCI was assessed using VerifyNow assays. The extent to which HPR was associated with ST risk according to MI presentation was explored by comparing the estimated effect sizes for MI and UA versus non-ACS in two separate multivariable Cox models, one without HPR as a covariate (total effect of clinical presentation) and one with HPR as a covariate (effect of clinical presentation after accounting for HPR).
Results:
Of 8,582 patients, 2,063 presented with MI, 2,370 with UA, and 4,149 with non-ACS. Incidence of HPR was 48.0%, 43.3%, and 39.8%, respectively (p < 0.001). Within the first 30 days post-PCI, patients presenting with MI had an increased ST risk compared with non-ACS patients (hazard ratio [HR], 4.52; 95% confidence interval [CI], 2.01-10.14; p < 0.001). After 30 days, relative ST risks were progressively lower and no longer significant between groups (31 days to 1 year post-PCI: HR, 1.97; 95% CI, 0.80-4.85; >1 year post-PCI: HR, 0.89; 95% CI, 0.27-2.92). The elevated ST risk in MI patients within 30 days was largely confined to those with HPR on clopidogrel (HR, 5.77; 95% CI, 2.13-15.63; p < 0.001).
Conclusions:
The authors concluded that increased ST risk in patients with MI was greatest in the first 30 days post-PCI and was predominantly observed among those with increased HPR on clopidogrel.
Perspective:
This post hoc study reports a gradient of ST risk during 2-year follow-up after PCI based on the initial acuity of clinical presentation, ranging from STEMI (highest ST risk) to non-ST-segment elevation MI (NSTEMI) to UA to non-ACS (lowest ST risk). Furthermore, the increased risk of ST in ACS patients was greatest in the first 30 days after PCI and this increased risk of early ST was largely confined to patients with increased HPR on clopidogrel. Of note, among patients without HPR, there was no significant association between clinical presentation and ST risk in any period. These data underscore the importance of adequate P2Y12 inhibition after MI, especially within the first 30 days after stent implantation, preferably with the use of newer potent P2Y12 inhibitors (prasugrel or ticagrelor, as recommended in the American College of Cardiology Foundation/American Heart Association guidelines).
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Interventions and ACS, Interventions and Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, Angina, Unstable, Aspirin, Blood Platelets, Drug-Eluting Stents, Myocardial Infarction, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Risk, Secondary Prevention, ST Elevation Myocardial Infarction, Stents, Thrombosis
< Back to Listings
