STENT THROMBOSIS: WHICH IMPACT IN REAL CLINICAL PRACTICE? Giuseppe Biondi Zoccai Divisione di...

STENT THROMBOSIS: STENT THROMBOSIS: WHICH IMPACT IN REAL WHICH IMPACT IN REAL

CLINICAL PRACTICE?CLINICAL PRACTICE?

Giuseppe Biondi ZoccaiGiuseppe Biondi Zoccai

Divisione di Cardiologia, Università di TorinoDivisione di Cardiologia, Università di Torino

Ospedale S. Giovanni Battista “Molinette” TorinoOspedale S. Giovanni Battista “Molinette” Torino

[email protected]@gmail.com

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Learning goals

• What is stent thrombosis?

• Can I predict stent thrombosis?

• What is the real impact of stent thrombosis?

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Learning goals




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Failing stents: thrombosis vs restenosis

Schuchman, New Engl J Med 2006

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Stent thrombosis in the medical literature

Google Scholar searched for “stent AND thrombosis” on 8 June 2010

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History of stent thrombosis

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3,51,4 0,8 0,6 1,5 0,9 1,6 1

02468

1012141618

PS - 1991 STRESS -1995

Colombo -1995

ISAR -1996

STARS -1997

Moussa -1999

Cutlip -2001

Wenaweser - 2005

Moreno -2006

Acu

te a

nd s

ubacu

te s

tent

thro

mbosi

s (%

)

IMPACT OF DUAL ANTIPLATELET THERAPY AND HIGH PRESSURE DILATION

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Definition of stent thrombosis

• Acute occlusion of a previously patent stent• It is a clinical syndrome (presents with acute coronary syndrome or sudden death – if silent cannot be defined stent thrombosis)

• It is not due to new plaque rupture at distant site

• There was no severe restenosis with final occlusion

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Academic Research Consortium definitions

•Definite:• Clinical syndrome (ACS or AMI)• and angiographic evidence of thrombus or occlusion• or pathologic evidence of acute thrombosis

•Probable:• Unexplained death < 30 days• or target vessel AMI without angiographic confirmation of thrombosis or other identified culprit lesion

•Possible:• Unexplained death after 30 days

Cutlip et al, Circulation 2007

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Timing of stent thrombosis

Type Occurrence* IncidenceAcute ≤1 day +

Subacute 2-30 days +++Late 2-12 months ++

Very late >1 year ++

*after PCI

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Learning goals




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Mechanisms of thrombosis: Virchow's triad

BLOOD FLOW

VESSEL

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Mechanisms of stent thrombosis

PATIENT FACTORS

LESION FACTORS

PROCEDURAL & MEDICAL

RX FACTORS

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Genetic variability in risk of stent thrombosis

Mega et al, New Engl J Med 2009

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Predicting thrombosis according to diabetes

Machecourt et al, J Am Coll Cardiol 2009

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Predicting thrombosis according to stent length

Moreno et al, J Am Coll Cardiol 2005

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What about late stent thrombosis?

McFadden et al, Lancet 2004

€

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Impact of antiplatelet therapy discontinuation

Kimura et al, Circulation 2009

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Impact of antiplatelet therapy intensity

Mehta et al, ESC 2009

Clopidogrel 600+150 mg

Clopidogrel 300+75 mg

P

Definite stent thrombosis

0.7% 1.2% 0.002

Myocardial infarction 2.0% 2.6% 0.012

Stroke 0.4% 0.4% 0.59

Cardiovascular death 1.9% 1.9% 0.68

Myocardial infarction or stent thrombosis

3.0% 3.7% 0.008

Cardiovascular death, myocardial infarction, or

stroke3.9% 4.5% 0.036

30-day results of the CURRENT-OASIS 7 Trial

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Predictors of drug-eluting stent thrombosis

Iakovou et al, JAMA 2005

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Predictors of stent thrombosis after ACS

Van Werkum et al, J Am Coll Cardiol 2009

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Any synthesis possible?

Capodanno et al, Clin Res Cardiol 2009

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Any synthesis possible?

Capodanno et al, Clin Res Cardiol 2009

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Learning goals




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Timing and incidence of stent thrombosis

StentsEarly stent thrombosis

Late stent thrombosis

Very late stent

thrombosis

SES vs BMS1

0.5% vs 0.3%

0.1% vs 1.0%

0.9% vs 0.4%

PES vs BMS1

0.5% vs 0.5%

0.4% vs 0.3%

0.9% vs 0.6%

ZES vs BMS2

0.3% vs 1.2%

0.3% vs 0.1%

0.1% vs 0.1%

EES vs PES3 0.4% vs 0

0.3% vs 0.6%

0.3% vs 1.0%

1Mauri et al, New Engl J Med 20072Leon, TCT 20083Stone et al, Circulation 2009

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Incidence of stent thrombosis in Bern & Rotterdam

Daemen et al, Lancet 2007

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Incidence of stent thrombosis in Sweden

Lagerqvist et al, Circulation Int 2009

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Outlook after stent thrombosis

Van Werkum et al, Circulation 2009

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Impact of BMS thrombosis

Cutlip et al, Circulation 2001

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Impact of definite DES thrombosis

Kuchulakanti et al, Circulation 2006

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Impact of definite or probable DES thrombosis

Mauri et al, New Engl J Med 2007

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More on impact of DES thrombosis


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Stent thrombosis in further perspective


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Take home messages

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Take home messages

• Stent thrombosis is a clinically important event, causing often death or myocardial infarction in those experiencing it

• Stent thrombosis is however rare, but it can be predicted by patient and lesion factors, and modulated by procedural, pharmacologic and other treatment decisions

• Thus, when addressing the issue of stent thrombosis, it is crucial to individualize management strategies in order to maximize benefits and minimize risks

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Thank you for your attention

For any correspondence: [email protected]

For these and further slides on these topics feel free to visit the

metcardio.org website:http://www.metcardio.org/slides.html

STENT THROMBOSIS: WHICH IMPACT IN REAL CLINICAL PRACTICE? Giuseppe Biondi Zoccai Divisione di...

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