Incidence, angiographic and clinical predictors, and impact of stent thrombosis: a 6-year survey of 6,545 consecutive patients

Factors Impacting Stent Thrombosis in Patients With Percutaneous Coronary Intervention and Coronary Stenting: A Systematic Review and Meta-Analysis

Stent thrombosis (ST) is a frequently reported complication in cardiac patients with percutaneous coronary intervention (PCI) that adversely impacts their prognostic outcomes. Medical literature reveals several baseline characteristics of PCI patients that may predict their predisposition to ST and its potential complications. Our systematic review and meta-analysis aimed to determine the diagnostic significance of these baseline parameters in terms of determining the risk of ST among adult patients with PCI. 

We statistically evaluated 18 baseline characteristics of more than 15,500 PCI patients to delineate their stent thrombosis attribution. We included a number of articles focusing on baseline parameters in-stent thrombosis-related PCI scenarios. We explored the articles of interest based on inclusion/exclusion parameters across PubMed, JSTOR, Cochrane library, Google Scholar, and Embase. Medical subject headings (MeSH) words included “stent thrombosis,” “percutaneous coronary intervention,” and “coronary stenting.” We extracted the research articles published between 2005 and 2021 on April 20, 2021. The included studies also focused on procedures and clinical factors concerning their association with PCI-related ST.

Our findings ruled out the progression of abnormal left ventricular ejection fraction (LVEF)-related stent thrombosis in PCI patients (odds ratio {OR}: 9.68, 95% CI: 1.88-49.90, p=0.007). We found an insignificant clinical correlation between stent thrombosis and PCI in the setting of acute coronary syndrome (ACS). Our study outcomes further revealed the absence of stent thrombosis in PCI patients with antiplatelet prescription (OR: 32.42, 95% CI: 21.28-49.39). The findings affirmed the absence of ST in PCI patients receiving aspirin therapy (OR: 32.77, 95% CI: 18.73-57.34; OR: 4.59, 95% CI: 1.97-10.73). The majority of the included studies negated the clinical correlation of stent thrombosis with diabetes mellitus in the setting of PCI (OR: 0.49, 95% CI: 0.06-3.78). Our study did not reveal statistically significant results based on stent thrombosis in PCI patients with drug-eluting stents (OR: 2.91, 95% CI: 0.35-24.49). The findings also did not reveal the impact of cardiac biomarker elevation on stent thrombosis in PCI patients (OR: 8.42, 95% CI: 2.54-27.98, p=0.0005). Eight studies revealed a statistically insignificant correlation between myocardial infarction and stent thrombosis in PCI scenarios (OR: 2.69, 95% CI: 0.89-8.11, p=0.08). The clinical correlation between PCI and stent thrombosis/major bleeding in the setting of hypertension also proved statistically insignificant at 0.67 (OR: 1.31, 95% CI: 0.38-4.51, p=0.97). The study findings did not correlate mean body mass index and multivessel coronary artery disease with ST in PCI scenarios (OR: 1.98, 95% CI: 0.02-239.58, p=0.78; OR: 1.09, 95% CI: 0.58-2.04, p=0.80). Only two studies revealed statistically significant results confirming stent thrombosis in PCI patients with a prior history of PCI (OR: 0.49, 95% CI: 0.23-1.06; OR: 0.33, 95% CI: 0.02-5.59; p=0.03).

Our findings question the clinical significance of baseline characteristics in terms of predicting stent thrombosis in PCI patients. The results support the requirement of future studies to investigate complex interactions between procedural, medicinal, genetic, and patient-related factors contributing to the development of stent thrombosis in PCI patients. 

Incidence, Predictors, and Outcomes of Acute and Sub-acute Stent Thrombosis after Emergency Percutaneous Coronary Revascularization with Drug-Eluting Stents: A Prospective Observational Study

Background:

Stent thrombosis (ST) remains the most feared complication of percutaneous coronary intervention (PCI). Therefore, this study aimed to determine acute and sub-acute ST incidence, predictors, and outcomes after primary PCI.

Methods:

This prospective observational study included patients who had undergone primary PCI at a tertiary care cardiac center. All the patients were followed at 30-days of index hospitalization for the incidence of acute or sub-acute ST. ST was further categorized as definite, probable, or possible per the Academic Research Consortium definition. All the survivors of ST were followed after 6-months for the incidence of major adverse cardiovascular events.

Results:

An aggregate of 1756 patients were included with 79% (1388) male patients and mean age was 55.59 ± 11.23 years. The incidence of ST was 4.9% (86) with 1.3% (22) acute and 3.6% (64) sub-acute. ST was categorized as definite in 3.3% (58) and probable in 1.6% (28). Independent predictor of ST were observed to be male gender (odds ratio (OR); 2.51 [1.21–5.2]), left ventricular end-diastolic pressure ≥20 mmHg (OR; 2.55 [1.31–4.98]), and pre-procedure thrombolysis in myocardial infarction (TIMI) flow 0 (OR; 3.27 [1.61–6.65]). Cumulative all-cause mortality among patients with ST after 164.1 ± 76.2 days was 46.5% (40/86).

Conclusion:

We observed a substantial number of patients vulnerable to the acute or sub-acute ST after primary PCI. Male gender, LVEDP, pre-procedure TIMI flow grade can be used to identify and efficiently manage highly vulnerable patients.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Comparison of 2-Stenting Strategies Depending on Sequence or Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era - Analysis From the COBIS (Coronary Bifurcation Stenting) III Registry

BACKGROUND

It has not been determined which specific 2-stenting strategy is the best for bifurcation lesions. Our aim was to investigate the clinical outcomes of various 2-stenting strategies in the era of 2nd-generation drug-eluting stents (2G-DES).Methods and Results:We analyzed 454 patients who finally underwent 2-stenting for a bifurcation lesion, from among 2,648 patients enrolled in the COBIS III registry. The primary outcome was target lesion failure (TLF). Patients were analyzed according to stenting sequence (provisional [main vessel stenting first] vs. systemic [side branch stenting first]) and stenting technique (crush vs. T vs. culotte vs. kissing/V stenting). Overall, 4.4 years' TLF after 2-stenting treatment for bifurcation lesion was excellent: TLF 11.2% and stent thrombosis 1.3%. There was no difference in TLF according to 2-stenting strategy (11.1% vs. 10.5%, P=0.990 for provisional and systemic sequence; 8.6% vs. 14.4% vs. 12.9% vs. 12.2%, P=0.326 for crush, T, culotte, kissing/V technique, respectively). Only left main (LM) disease and a shorter duration of dual antiplatelet therapy (DAPT) were associated with TLF. The distribution of DAPT duration differed between patients with and without TLF, and the time-point of intersection was 2.5 years. Also, the side branch was the most common site of restenosis.

CONCLUSIONS

The stenting sequence or technique did not affect clinical outcomes, but LM disease and shorter DAPT were associated with TLF, in patients with bifurcation lesions undergoing 2-stenting with 2G-DES.

Management of acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura, the value of optical coherence tomography: a case report

BACKGROUND

Treating myocardial infarction in the setting of immune thrombocytopenic purpura (ITP) is always a challenge especially if the platelet count is labile. Cardiologists dealing with such patients should keep a delicate balance between thrombotic and bleeding complications.

CASE SUMMARY

A 50-year-old gentleman with treatment-challenging ITP presented with acute inferior ST elevation myocardial infarction after receiving recent intravenous immunoglobulin. Using optical coherence tomography (OCT) guidance, it was decided to treat him with percutaneous old balloon angioplasty especially with the labile nature of his platelet count. Subsequently, dual antiplatelet therapy was a challenge and he remained on clopidogrel for a period of only 10 weeks.

CONCLUSION

This case highlights the rare presentation of patients with ITP with thrombotic complications and the usefulness of OCT in formulating a management plan.

Direct comparison of predictive performance of PRECISE-DAPT versus PARIS versus CREDO-Kyoto: a subanalysis of the ReCre8 trial

Background

Multiple scores have been proposed to guide risk stratification after percutaneous coronary intervention. This study assessed the performance of the PRECISE-DAPT, PARIS and CREDO-Kyoto risk scores to predict post-discharge ischaemic or bleeding events.

Methods

A total of 1491 patients treated with latest-generation drug-eluting stent implantation were evaluated. Risk scores for post-discharge ischaemic or bleeding events were calculated and directly compared. Prognostic performance of both risk scores was assessed with calibration, Harrell’s c‑statistics net reclassification index and decision curve analyses.

Results

Post-discharge ischaemic events occurred in 56 patients (3.8%) and post-discharge bleeding events in 34 patients (2.3%) within the first year after the invasive procedure. C‑statistics for the PARIS ischaemic risk score was marginal (0.59, 95% confidence interval (CI) 0.51–0.68), whereas the CREDO-Kyoto ischaemic risk score was moderate (0.68, 95% CI 0.60–0.75). With regard to post-discharge bleeding events, CREDO-Kyoto displayed moderate discrimination (c-statistic 0.67, 95% CI 0.56–0.77), whereas PRECISE-DAPT (0.59, 95% CI 0.48–0.69) and PARIS (0.55, 95% CI 0.44–0.65) had a marginal discriminative capacity. Net reclassification index and decision curve analysis favoured CREDO-Kyoto-derived bleeding risk assessment.

Conclusion

In this contemporary all-comer population, PARIS and PRECISE-DAPT risk scores were not resilient to independent testing for post-discharge bleeding events. CREDO-Kyoto-derived risk stratification was associated with a moderate predictive capability for post-discharge ischaemic or bleeding events. Future studies are warranted to improve risk stratification with more focus on robustness and rigorous testing.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01486-y) contains supplementary material, which is available to authorized users.

Clinical outcomes after percutaneous coronary intervention for early versus late and very late stent thrombosis: a systematic review and meta-analysis

Whether the clinical outcomes of stent thrombosis (ST) are different when stratified by time of occurrence remains unclear. The objective of this study was to compare the short- and long-term clinical outcomes after percutaneous coronary intervention (PCI) for early stent thrombosis (EST) versus late stent thrombosis (LST) and very late stent thrombosis (VLST). We enrolled eligible studies searched from the main electronic databases (EMBASE, PubMed, Cochrane). The primary endpoints were in-hospital, 30-day, 1-year and long-term mortality. The secondary endpoints included recurrent stent thrombosis (RST) and target vessel/lesion revascularization (TVR/TLR) during hospitalization, at 30 days, at 1 year and at long-term follow-up. A total of 23 studies with 17,592 patients were included. Compared with mortality rates of the late and very late thrombosis (LST/VLST) group, in-hospital (P = 0.004), 30-day (P < 0.00001), 1-year (P < 0.00001) and long-term mortality rates (P = 0.04) were significantly higher in the EST group. The in-hospital TVR/TLR rates were similar between the EST group and the LST/VLST group. However, a higher trend in TVR/TLR rate at 30 days and a significantly higher TVR/TLR rate at 1 year (P = 0.002) as well as at long-term follow up (P = 0.009) were found in the EST group. EST patients also trended toward higher risk of RST in both short- and long-term follow-up than LST/VLST patients, although differences were not statistically significant. After PCI treatment, patients with EST have worse clinical outcomes in both short- and long-term follow-up than patients with LST/VLST. Further studies are warranted to determine the optimal treatment strategies for EST.

Dual anti-thrombotic treatment with direct anticoagulants improves clinical outcomes in patients with Atrial Fibrillation with ACS or undergoing PCI. A systematic review and meta-analysis

Background

There is recent new evidence regarding the combined use of direct oral antiocoagulants and antiplatelet agents in patients with Atrial Fibrillation undergoing PCI.

Purpose

To compare the efficacy of dual antithrombotic treatment (DAT) including a direct oral anticoagulant (DOAC) and an antiplatelet agent versus triple antithrombotic treatment (TAT) with a vitamin K antagonist (VKA).

Data sources

PubMed, SCOPUS and Google Scholar from through 09/09/2019; references of eligible studies; relevant scientific sessions abstracts and cardiology websites.

Study selection

Randomized controlled trials that compared DAT including a DOAC with TAT including a VKA and that reported at least the rates of stroke, Stent thrombosis and bleeding.

Data extraction

Two investigators independently extracted study data and assessed study quality.

Data synthesis

Four randomized trials that compared DAT including a DOAC with TAT including a VKA were available. Among these, one trial included two independent treatment arms with different DOAC dose, both compared against TAT. For this reason, the two arms were treated independently, resulting in 5 randomized comparisons available for meta-analysis, with a total of 8654 patients involved. The primary safety endpoint was significantly lower in the DAT arm (14.4%) compared to the TAT arm (23%) (RD = -0.08; p<0.001). In addition, we found no significant difference in the incidence of stroke between the treatment arms (p = 0.23). Similarly, no significant difference in the incidence of Stent Thrombosis between the treatment arms (p = 0.08).

Limitations

All trials included were open-label, even though data were blindly analyzed. Qualifying criteria are heterogeneous.

Conclusions

Compared TAT including a VKA, a therapeutic DAT regimen including a DOAC was associated with a significant reduction of the primary safety endpoint in AF patients undergoing PCI with stent implantation for an ACS or chronic coronary syndrome, while no significant difference was found in the rate of ischemic adverse events, including stroke, acute myocardial infarction or stent thrombosis.

The Role of Novel Oral Anticoagulants and Antiplatelet Therapy after Percutaneous Coronary Intervention: Individualizing Therapy to Optimize Outcomes

The number of patients undergoing percutaneous coronary intervention (PCI) who mandate additional oral anticoagulant therapy has been increasing. Dual antiplatelet therapy (DAPT) is associated with reduced ischemic events including stent thrombosis, myocardial infarction and stroke following PCI. However, the tradeoff is an increased risk for bleeding while on DAPT. The addition of a novel oral anticoagulant (NOAC) further increases the likelihood of bleeding while on antiplatelet therapy. Thus, the overall risks and benefits for each patient undergoing PCI on NOAC must be assessed and therapy individualized to ensure optimal therapy for each unique situation. Patients on NOAC undergoing PCI should undergo routine assessment with intravascular imaging as the role of high-risk lesion-related features have increased importance prior to determining optimal duration of treatment with DAPT. We review the best practices for the pharmacologic management of patients requiring anticoagulation with NOAC who are treated with PCI and require antiplatelet therapy.