Stent thrombosis incidence as a function of treatment with antiplatelets


 * Associate Editors-In-Chief: Smita Kohli, M.D.; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Incidence of stent thrombosis while on dual antiplatelet therapy
Supportive trial data: Incidence of EARLY ST

This category would include the incidence of acute and subacute stent thrombosis.
 * In a prospective observational cohort study of 2229 patients with DES (sirolimus or paclitaxel), ST occurred in 1.3% with a 0.6% subacute ST in patients who were on dual antiplatelet therapy.


 * In a long-term follow-up study of 1911 patients with DES on dual antiplatelet therapy, stent thrombosis occurred in 0.8% patients after DES implantation with 1.3% stent thrombosis within 6 hours to 20.4 months. The incidence of ST was 3.3% in patients with complete discontinuation of antiplatelet therapy, 7.8% in patients with premature discontinuation and 0.6% in patients who did not discontinue antiplatelet therapy


 * Results from an observational study involving 15157 patients with sirolimus-eluting stents (SES), reported that the rates of acute ST was 0.13% and subacute ST was 0.56%, representing a 12-month actuarial incidence of 0.87%. Thereby suggests a high degree of safety of SES, with a rate of stent thrombosis similar to that observed in randomized trials.

Supportive trial data: Incidence of LATE ST

This category would include the incidence of late and very late stent thrombosis.


 * In a cohort of 2006 patients with PES and SES up to a mean follow-up of 15 months with a follow up rate of 98% of the patients, no ST occurred while patients were on dual antiplatelet therapy.


 * In a long-term follow-up study of 1911 patients with DES on dual antiplatelet therapy, ST occurred in 0.8% patients after DES with the 0.6% of late stent thrombosis, which was similar to that for BMS.

Incidence of stent thrombosis while on single antiplatelet therapy
Supportive trial data: Incidence of EARLY ST

This category would include acute and subacute ST while on single antiplatelet therapy.


 * This is an uncommon category as most patients are on dual antiplatelet medications.How ever it has been suggested that those patients who:
 * suboptimally loaded with dual antiplatelet therapy,
 * receive bivalirudin, may be at an increased risk of ST during the waning of the effect of bivalirudin and
 * during the time period until dual antiplatelet effects becomes adequate.
 * Another scenario is the patient who is intolerant to one antiplatelet medication. This again is a very uncommon situation, as hospitals use aspirin desensitization.

Supportive trial data: Incidence of LATE ST

This category would include late ST and very late ST.


 * Overall the incidence of late ST in patients who presented on aspirin monotherapy was 0.25%. How ever no data was reported as to the proportion of patients who were on aspirin monotherpay at that time. 60% of the patients who presented with late ST and were on aspirin monotherpay after 6 months of the procedure. It is possible that the majority of the patients may have been on aspirin monotherapy at that time, yielding an incidence of ST for this group of 0.25%.


 * In a study involving 1911 patients who had DES 0.15% of patients who presented with late ST were on one antiplatelet therapy. How ever it is not clear as to the number of patients in the whole cohort who were on single antiplatelet therapy . In one study, hazard ratio for late ST on premature discontinuation of antiplatelet therapy was 57.13 (14.84 - 219.96).

Incidence of stent thrombosis with no antiplatelet therapy
Supportive trial data: Incidence of EARLY ST


 * This is an unlikely scenario in the current environment.

Supportive trial data: Incidence of LATE ST


 * On long term follow up to 19.4 months, 121 patients with DES had complete interruption of antiplatelet therapy with a ST rate of 3.3 % in that group. (this represented an overall risk of 0.2 % when applied to the whole study population.) In the same group the rate of ST when both antiplatelet therapies were stopped within 6 months of stent implantation was 9%.


 * Two patients presented with ST who were 343 and 335 days following DES implantation. They had ceased dual antiplatelet therapy within 14 days of ST . Data of other patients who had a DES with no antiplatelet cover for the same duration was not available.