Frequency and predictors of stent thrombosis after percutaneous coronary intervention in acute myocardial infarction
George D Dangas1, Adriano Caixeta, Roxana Mehran
1Cardiovascular Institute, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA. george.dangas@mssm.edu
Insights
Stent thrombosis after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction is common, occurring similarly with drug-eluting or bare metal stents. Optimizing antithrombin and antiplatelet therapy may reduce this risk.
Area of Science:
- Cardiology
- Interventional Cardiology
- Thrombosis Research
Background:
- Persistent concerns exist regarding stent thrombosis risk following primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).
- Understanding factors influencing stent thrombosis is crucial for improving patient outcomes after PCI.
Purpose of the Study:
- To evaluate the incidence and predictors of stent thrombosis in patients undergoing primary PCI for STEMI.
- To compare stent thrombosis rates between different antithrombotic strategies and stent types.
Main Methods:
- The HORIZONS-AMI trial randomized 3602 STEMI patients undergoing primary PCI to heparin plus a glycoprotein IIb/IIIa inhibitor (GPI) or bivalirudin monotherapy.
- Stent thrombosis events were analyzed within 2 years, comparing drug-eluting stents (DES) vs. bare metal stents (BMS) and bivalirudin vs. heparin/GPI therapy.
Main Results:
- Overall stent thrombosis occurred in 4.4% of patients within 2 years, with similar rates for DES and BMS (4.4%).
- Bivalirudin monotherapy showed similar 2-year stent thrombosis rates (4.3%) compared to heparin/GPI (4.6%).
- Acute stent thrombosis was higher with bivalirudin (1.4%) vs. heparin/GPI (0.3%), but very late events were lower with bivalirudin (2.8% vs. 4.4%).
Conclusions:
- Stent thrombosis is a significant event within 2 years post-primary PCI for STEMI, occurring with similar frequency across stent types and major antithrombotic regimens.
- Early administration of antithrombin therapy and potent antiplatelet agents may be key to reducing stent thrombosis in STEMI patients.
Background:
Concerns persist regarding the risk of stent thrombosis in the setting of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.
Methods And Results:
The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial included 3602 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention who were randomized to heparin plus a glycoprotein IIb/IIIa inhibitor (GPI) (n=1802) versus bivalirudin monotherapy (n=1800). Stents were implanted in 3202 patients, including 2261 who received drug-eluting stents and 861 who received only bare metal stents. Definite or probable stent thrombosis within 2 years occurred in 137 patients (4.4%), including 28 acute events (0.9%), 49 subacute events (1.6%), 32 late events (1.0%), and 33 very late events (1.1%). The 2-year cumulative rates of stent thrombosis were 4.4% with both drug-eluting stents and bare metal stents (P=0.98) and 4.3% versus 4.6% in patients randomized to bivalirudin monotherapy versus heparin plus a GPI, respectively (P=0.73). Acute stent thrombosis occurred more frequently in patients assigned to bivalirudin compared with heparin plus a GPI (1.4% versus 0.3%; P<0.001), whereas stent thrombosis after 24 hours occurred less frequently in patients with bivalirudin compared with heparin plus a GPI (2.8% versus 4.4%; P=0.02). Pre-randomization heparin and a 600-mg clopidogrel loading dose were independent predictors of reduced acute and subacute stent thrombosis, respectively.
Conclusions:
Stent thrombosis is not uncommon within the first 2 years after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction, and occurs with similar frequency in patients receiving drug-eluting stents versus bare metal stents and bivalirudin alone versus heparin plus a GPI. Optimizing adjunct pharmacology including early antithrombin therapy preloading with a potent antiplatelet therapy may further reduce stent thrombosis in ST-segment elevation myocardial infarction.
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