Ticlopidine and subcutaneous heparin as an alternative regimen following coronary stenting

Subacute thrombosis of coronary stents may occur up to the end of the first month after their implantation and remains the major problem associated with the technique. A cohort of 238 patients with placement of one or more stents in 244 arteries was monitored for this period. All patients were given 500 mg/day of ticlopidine (started 3 days before) and a push dose of 10,000 IU of heparin during the procedure, then 1,000-1,500 IU/hr for 20 hr. Following removal of the arterial introducer, they were kept on subcutaneous heparin for 1 week and ticlopidine (500 mg/day) for 3-6 months. Nine patients (3.8%) showed evidence of thrombosis at 7 days. The overall thrombosis rate at 30 days was 4.2% (3.5% for elective stents, as compared with 7.9% associated with occlusive dissections). Emergency treatment by further angioplasty (8 cases) and intracoronary thrombolysis (5 cases) was undertaken. Complications were as follows: 5 deaths (2%), 3 MI (1.2%), 2 non-Q MI (1.7%). Three predictive factors for subacute thrombosis were identified: age < 70 (p = 0.00006), unstable angina (p = 0.006) and arterial diameter less than 3 mm (p = 0.043). The peripheral vascular complication rate was 4.6%. This study suggests that preventive treatment with ticlopidine appears to reduce the incidence of subacute thrombosis of stents in patients > 70 years of age. Furthermore, the combination of ticlopidine and heparin facilitates laboratory monitoring after stenting. Stenting is thought to represent definitive treatment in situations where placement for occlusive dissection is the indication.