Are at least 12 months of dual antiplatelet therapy needed for all patients with drug-eluting stents? All patients with drug-eluting stents need at least 12 months of dual antiplatelet therapy

Organ transplantation and drug eluting stents: Perioperative challenges

Patients listed for organ transplant frequently have severe coronary artery disease (CAD), which may be treated with drug eluting stents (DES). Everolimus and zotarolimus eluting stents are commonly used. Newer generation biolimus and novolimus eluting biodegradable stents are becoming increasingly popular. Patients undergoing transplant surgery soon after the placement of DES are at increased risk of stent thrombosis (ST) in the perioperative period. Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel and ticagrelor is instated post stenting to decrease the incident of ST. Cangrelor has recently been approved by Food and Drug Administration and can be used as a bridging antiplatelet drug. The risk of ischemia vs bleeding must be considered when discontinuing or continuing DAPT for surgery. Though living donor transplant surgery is an elective procedure and can be optimally timed, cadaveric organ availability is unpredictable, therefore, discontinuation of antiplatelet medication cannot be optimally timed. The type of stent and timing of transplant surgery can be of utmost importance. Many platelet function point of care tests such as Light Transmittance Aggregrometry, Thromboelastography Platelet Mapping, VerifyNow, Multiple Electrode Aggregrometry are used to assess bleeding risk and guide perioperative platelet transfusion. Response to allogenic platelet transfusion to control severe intraoperative bleeding may differ with the antiplatelet drug. In stent thrombosis is an emergency where management with either a drug eluting balloon or a DES has shown superior outcomes. Post-transplant complications often involved stenosis of an important vessel that may need revascularization. DES are now used for endovascular interventions for transplant orthotropic heart CAD, hepatic artery stenosis post liver transplantation, transplant renal artery stenosis following kidney transplantation, etc. Several antiproliferative drugs used in the DES are inhibitors of mammalian target of rapamycin. Thus they are used for post-transplant immunosuppression to prevent acute rejection in recipients with heart, liver, lung and kidney transplantation. This article describes in detail the various perioperative challenges encountered in organ transplantation surgery and patients with drug eluting stents.

Practice Variation in Triple Therapy for Patients With Both Atrial Fibrillation and Coronary Artery Disease: Insights From the ACC's National Cardiovascular Data Registry

OBJECTIVES

The aim of this study was to test the hypothesis that in the United States substantial practice variation exists in triple therapy prescribing practices, unrelated to measured patient factors.

BACKGROUND

Recent data have shown that the risk of bleeding on dual antiplatelet therapy and oral anticoagulation ("triple therapy") is high, although the optimal strategy for patients with atrial fibrillation and coronary artery disease remains unclear.

METHODS

Using the PINNACLE (National Practice Innovation and Clinical Excellence) registry, we identified 79,875 unique patients with both atrial fibrillation/atrial flutter and myocardial infarction and/or coronary stenting within 12 months. Using triple therapy as a binary outcome variable, we created a mixed-effects logistic regression model with patient factors as fixed effects and practice site as a random effect. Patient factors included age, sex, diabetes, congestive heart failure, hypertension, peripheral arterial disease, prior stroke or transient ischemic attack, history of systemic embolization, and dyslipidemia. The model was assessed with a median odds ratio to assess practice variation after adjustment for patient factors.

RESULTS

After adjustment for patient factors, significant practice variation was suggested by a median odds ratio of 2.78 (95% confidence interval: 2.33 to 3.23). In particular, this suggests that 2 randomly selected practices would differ in their likelihood of prescribing triple therapy for an identical patient by a factor of nearly 3.

CONCLUSIONS

In the United States, there is substantial practice variation in prescribing triple therapy to eligible patients even after adjustment for patient clinical characteristics. These results suggest that opportunities exist to improve the quality of care of this sizable population.