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Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Relation between clopidogrel discontinuation and early cardiovascular events after percutaneous coronary intervention
Gilles Lemesle1, Rebecca Torguson, Laurent Bonello
1Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA.
Insights
Stopping clopidogrel soon after drug-eluting stent (DES) implantation increases cardiovascular events due to unhealed vessels, not a rebound effect. The risk diminishes significantly after 10.2 months post-procedure.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- Clopidogrel discontinuation after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation is linked to stent thrombosis.
- The underlying mechanism, whether a rebound phenomenon or lack of vessel healing, remains unclear.
Purpose of the Study:
- To investigate the association between clopidogrel cessation timing and cardiovascular events post-PCI with DES.
- To differentiate between rebound phenomenon and vessel healing status as causes of post-cessation events.
Main Methods:
- A retrospective analysis of 1,903 patients undergoing PCI with DES implantation between 2003 and 2007.
- Patients were categorized into four groups based on clopidogrel cessation timing: within 1 month, 1-6 months, 6-12 months, and after 12 months.
- Composite endpoints of death, myocardial infarction, and stent thrombosis were assessed at 30 and 31-60 days post-cessation.
Main Results:
- The early event rate (0-30 days post-cessation) was significantly higher in patients stopping clopidogrel within one month (5.2%) compared to later cessation groups (0.6%-1.2%).
- Event rates between 31-60 days post-cessation were low and similar across all groups.
- Analysis as a continuous variable indicated that the event probability within 30 days post-cessation normalized to the 31-60 day interval after approximately 10.2 months post-PCI.
Conclusions:
- Immediate cardiac events after clopidogrel cessation are primarily attributed to insufficient vessel healing, not a rebound phenomenon.
- The risk associated with lack of healing decreases over time and appears to resolve around 10.2 months after PCI.
- Timing of clopidogrel cessation is critical, with later discontinuation associated with lower early cardiovascular event rates.
Aims:
Clopidogrel discontinuation after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation has been reported to correlate with stent thrombosis. Whether these events are a consequence of the rebound phenomenon or a lack of protection in unhealed vessels is unclear. This study aimed to determine the link between clopidogrel cessation and cardiovascular events after PCI with DES.
Methods And Results:
The population included 1,903 patients who underwent PCI with DES implantation from 2003 to 2007. We compared patients who stopped their clopidogrel within the first month (group 1, n=97), from one to six months (group 2, n=344), from six to 12 months (group 3, n=468), and after 12 months (group 4, n=994) following the PCI. In each group, the composite of death, myocardial infarction and stent thrombosis at 30 days and between 31 and 60 days after clopidogrel cessation was indexed. Baseline characteristics were similar among groups. The event rate observed in the 0-30 day interval following cessation was higher only in group 1 (5.2%) compared to all other groups: 1.2% (group 2), 0.9% (group 3) and 0.6% (group 4) (p=0.004). The event rates from 31 to 60 days following cessation were low and similar among the four groups. When the elapsed time between the index PCI and the clopidogrel cessation was analysed as a continuous variable, the probability of events occurring within the first 30 days became similar to that observed in the 31-60 day interval following cessation after a minimum of 10.2 months.
Conclusions:
Cardiac events seen immediately after clopidogrel cessation are not related to a rebound phenomenon, but are more likely influenced by the lack of healing at the time of cessation, which decreases over time. This increased risk related to the lack of healing seems to disappear after 10.2 months.
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