Impact of early versus late clopidogrel discontinuation on stent thrombosis following percutaneous coronary intervention with first- and second-generation drug-eluting stents.
Premature antiplatelet therapy discontinuation (ATD) after drug-eluting stent (DES) implantation is known to predict stent thrombosis (ST). However, recent data suggest that a shorter antiplatelet therapy duration is safe with newer generation DESs. The study aimed to compare the impact of early and late clopidogrel ATDs on ST in a real-world registry of first- and second-generation DES use. A total of 6,236 patients who underwent DES implantation were analyzed retrospectively: 4,217 received first-generation DESs (sirolimus- and paclitaxel-eluting stents) and 2,019 received second-generation DESs (everolimus-eluting stents). Within each DES cohort, patients were categorized into timing of clopidogrel discontinuation within 1 year: early (<3 months), late (3 to 12 months), and continued. ST rates and clinical outcomes at 1 year were analyzed. There were 341 patients (8.1%) in the first-generation DES group and 126 patients (6.2%) in the second-generation DES group who discontinued clopidogrel within the first year. Definite and probable ST rates were 3.8% for early ATD, 2.5% for late ATD, and 0.5% for continued (p = 0.001) in the first-generation DES cohort, whereas there were no definite or probable ST events in early and late ATDs and 0.5% for continued in the second-generation DES cohort. Major adverse cardiac event rates were 9.9% for early ATD, 5.6% for late ATD, and 0.9% for continued (p <0.001) in the first-generation DES cohort and 5.5% for early ATD, 7.4% for late ATD, and 1.5% for continued (p <0.001) in the second-generation DES cohort. In conclusion, ATD within the first year is associated with increased ST events with first-generation DESs, whereas ATD appears safe with second-generation DESs with regard to ST. However, ATD is associated with greater mortality and major adverse cardiac events in both first- and second-generation DESs. Thus, this study supports ATD if required based on physician discretion with the use of second-generation DESs but cannot rule out potential benefit for longer duration of dual antiplatelet therapy even when second-generation DESs are used.
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Joshua P
JP
Loh
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Rebecca
R
Torguson
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Lakshmana K
LK
Pendyala
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Alfazir
A
Omar
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Fang
F
Chen
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Lowell F
LF
Satler
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Augusto D
AD
Pichard
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC. Electronic address: ron.waksman@medstar.net.
Ron
R
Waksman
D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects* / Q000379:methods; D000077144:Clopidogrel; D015331:Cohort Studies; D003131:Combined Modality Therapy; D017023:Coronary Angiography / Q000379:methods; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000401:mortality / Q000628:therapy; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D054855:Drug-Eluting Stents / Q000009:adverse effects*; D000068338:Everolimus; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D017239:Paclitaxel / Q000494:pharmacology; D011475:Prosthesis Failure / Q000187:drug effects; D012042:Registries; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020123:Sirolimus / Q000031:analogs & derivatives / Q000494:pharmacology; D016019:Survival Analysis; D013927:Thrombosis / Q000209:etiology*; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives*; D013997:Time Factors; D016896:Treatment Outcome; D028761:Withholding Treatment
D000068338:Everolimus; D000077144:Clopidogrel; D013988:Ticlopidine; D017239:Paclitaxel; D020123:Sirolimus