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Published on: November 8, 2024
Stent Thrombosis Risk Over Time on the Basis of Clinical Presentation and Platelet Reactivity: Analysis From
Katherine H Chau1, Ajay J Kirtane1, Rachel M Easterwood2
1Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA.
Insights
Stent thrombosis risk is highest within 30 days after percutaneous coronary intervention (PCI) for myocardial infarction (MI), particularly with high platelet reactivity (HPR) on clopidogrel. This highlights the need for effective P2Y12 inhibition post-MI.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Pharmacology
Background:
- Stent thrombosis (ST) risk is elevated post-percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS) compared to stable ischemic heart disease.
- The precise timing of peak ST risk in ACS patients and the influence of high platelet reactivity (HPR) remain unclear.
Purpose of the Study:
- To determine the risk period for increased stent thrombosis (ST) following PCI in patients with acute coronary syndromes (ACS).
- To investigate the association between this heightened ST risk and high platelet reactivity (HPR).
Main Methods:
- Analysis of the ADAPT-DES registry data, comparing ST rates over 2 years post-PCI with drug-eluting stents.
- Patients were stratified into ACS (myocardial infarction [MI] or unstable angina) and non-ACS (stable ischemic heart disease) groups.
- Landmark analyses at 30 days and 1 year, with platelet reactivity assessed using VerifyNow assays for aspirin and clopidogrel.
Main Results:
- Patients with MI exhibited the highest ST rates within the first 30 days post-PCI (HR: 4.52) compared to non-ACS patients.
- This elevated risk in MI patients was primarily associated with high platelet reactivity (HPR) on clopidogrel (HR: 5.77).
- ST risk decreased significantly and became non-significant between groups after 30 days and 1 year post-PCI.
Conclusions:
- The highest risk for stent thrombosis after PCI in myocardial infarction patients occurs within the initial 30 days.
- High platelet reactivity on clopidogrel is a significant factor contributing to this early increased risk.
- Emphasizes the critical need for potent P2Y12 inhibition, particularly in the first 30 days post-stenting in MI patients.
Objectives:
The aim of this study was to determine the risk period for increased stent thrombosis (ST) after percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) and whether this increased risk is related to high platelet reactivity (HPR).
Background:
ST risk after PCI is higher among patients with ACS than those with stable ischemic heart disease. When ST risk is highest in patients with ACS and how that is affected by HPR is unknown.
Methods:
Using the ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) registry, ST rates during 2-year follow-up post-PCI with drug-eluting stents were compared among patients presenting with ACS (myocardial infarction [MI] or unstable angina) or stable ischemic heart disease (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.
Results:
Of 8,582 patients, 2,063 presented with MI, 2,370 with unstable angina, and 4,149 with non-ACS. Incidence rates of HPR were 48.0%, 43.3%, and 39.8%, respectively (p < 0.001). Within the first 30 days post-PCI, patients presenting with MI had increased ST risk compared with patients with non-ACS (hazard ratio [HR]: 4.52; 95% confidence interval [CI]: 2.01 to 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 to 4.85; >1 year post-PCI: HR: 0.89; 95% CI: 0.27 to 2.92). The elevated ST risk in patients with MI within 30 days was largely confined to those with HPR on clopidogrel (HR: 5.77; 95% CI: 2.13 to 15.63; p < 0.001).
Conclusions:
Among patients undergoing PCI, rates of ST during 2-year follow-up were highest in those with MI and lowest in those with non-ACS. Increased ST risk in patients with MI was greatest in the first 30 days post-PCI and was observed predominantly among those with increased HPR on clopidogrel. These findings emphasize the importance of adequate P2Y12 inhibition after MI, especially within the first 30 days after stent implantation.
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