Late Clinical Events After Clopidogrel Discontinuation May Limit the Benefit of Drug-Eluting Stents

Pfisterer, Matthias; Rocca, Hans Peter Brunner–La; Buser, Peter; Rickenbacher, Peter; Hunziker, Patrick; Müeller, Christian; Jeger, Raban; Bader, Franziska; Oßwald, Stefan; Kaiser, Christoph; Investigators, Basket-Late

doi:10.1016/j.jacc.2006.10.026

Cited by 1,227 publications

(651 citation statements)

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“…The high nonpersistence of clopidogrel and DAPT is in line with the results of the clinical trials and long‐term observational studies leading to ESC guideline recommendations on the use of antiplatelet drugs after coronary stenting for ACS 20, 21, 22, 23. DAPT should be used for at least 1 month after a bare metal stent (BMS) implantation, for at least 6 months after a drug‐eluting stent (DES) implantation and up to a maximum of 1 year, or longer in patients with a high cardiovascular and low bleeding risk, after which monotherapy with aspirin should be continued indefinitely 23.…”

Section: Discussionsupporting

confidence: 68%

Patterns of antiplatelet drug use after a first myocardial infarction during a 10‐year period

Yasmina

Boer

Deneer

et al. 2016

Brit J Clinical Pharma

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AimsThe aims of the present study were to assess antiplatelet drug use patterns after a first myocardial infarction (MI) and to evaluate the determinants of antiplatelet nonpersistence.MethodsThe present study was conducted in 4690 patients from the Utrecht Cardiovascular Pharmacogenetics cohort with a first MI between 1986 and 2010, who were followed for a maximum of 10 years. Medication use and event diagnosis were obtained from the Dutch PHARMO Record Linkage System. Antiplatelet drug users were classified as persistent users (gap between prescriptions ≤90 days), nonpersistent users (>90‐day gap and no refills), and restarters (a new prescription after a >90‐day gap). The association between potential determinants and antiplatelet nonpersistence was analysed using Cox regression.ResultsThe proportions of persistent users decreased from 84.0% at the 1‐year follow‐up to 32.8% at 10 years for any antiplatelet drug, and 77.3% to 27.5% for aspirin; and 39.0% to 6.4% for clopidogrel at 6 years. Most nonpersistent users restarted antiplatelet drugs later, leading to 89.3% overall antiplatelet drug users at 10 years after MI. Diabetes (hazard ratio [HR] 0.44; 0.32–0.60), hypertension (HR 0.77; 0.60–0.99), hypercholesterolaemia (HR 0.49; 0.39–0.62) and more recent MI diagnosis period (2003–2007: HR 0.69, 0.61–0.79; 2008–2010: HR 0.38, 0.19–0.77, compared to ≤ 2002 period) lowered the risk of antiplatelet nonpersistence, while vitamin K antagonist (VKA) comedication (HR 18.97; 16.91–21.28) increased this risk.ConclusionsA large proportion of patients with a first MI still used antiplatelet drugs after 10 years. The frequent discontinuations during this time frame are expected to reduce the effectiveness of antiplatelet drugs as secondary prevention of cardiovascular diseases. Diabetes, hypertension, hypercholesterolaemia, VKA comedication and MI diagnosis period were determinants of antiplatelet nonpersistence.

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Section: Discussionsupporting

confidence: 68%

Patterns of antiplatelet drug use after a first myocardial infarction during a 10‐year period

Yasmina

Boer

Deneer

et al. 2016

Brit J Clinical Pharma

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“…6 However, emerging data suggests that DESs may increase the risk of late thrombosis, and increase morbidity and mortality. 7,11 Recent data would suggest that there is a 2-fold increase in late deaths or MI after DES implantation versus BMS. 11 However, this issue is still controversial.…”

Section: Discussionmentioning

confidence: 99%

“…7,11 Recent data would suggest that there is a 2-fold increase in late deaths or MI after DES implantation versus BMS. 11 However, this issue is still controversial. Some studies suggest that DES may have an increased risk of very late thrombosis, but this may not increase overall mortality.…”

Section: Discussionmentioning

confidence: 99%

Cutting Balloon Angioplasty and Stent Implantation for Aorto‐ostial Lesions: Clinical Outcome and 1‐year Follow‐up

Nassar

Gotsman

Gerganski

et al. 2009

Clinical Cardiology

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Background: Percutaneous interventions for aorto-ostial narrowing of native coronary arteries are challenging because of early elastic recoil after the procedure and the high restenosis rate. Cutting balloon angioplasty may reduce this complication. Hypothesis: The purpose of the study was to evaluate the clinical outcomes of cutting balloon angioplasty and stent implantation for aorto-ostial lesions with a 1-year clinical follow-up. Methods: All patients with aorto-ostial lesions in our laboratory underwent cutting balloon angioplasty and were followed for approximately 1 year. Results: Forty-eight patients underwent balloon angioplasty; 36 of whom had lesions in the ostial right coronary artery, and 12 of whom had lesions in the left main coronary artery (LMCA). Thirty-five patients (73%) had a stent implanted. Procedural success was achieved in all patients. The in-hospital rate of major adverse cardiac events (MACEs) was 2.1% because of the death of 1 patient following urgent bypass surgery. Mean clinical follow-up was 11.6 ± 7 month. Twelve patients (27%) required repeat coronary angiography, and restenosis was found in 7 patients (16%). Six patients (13.6%) had MACEs. Conclusions: Cutting balloon angioplasty in combination with bare metal stent (BMS) implantation has a good clinical outcome. This technique should be compared with implantation of drug-eluting stents (DESs) in a controlled study.

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“…Although there were no differences in cumulative rates of death or MI between patients who received DES (versus BMS), higher rates of death and MI were observed after clopidogrel discontinuation in patients receiving DES (versus BMS; 4.9% versus 1.3%, respectively) at 18-month follow-up. 20 Additionally, a recently reported observational study in 4,666 patients who were event-free at 6-and 12-month follow-ups showed that clopidogrel use was a significant predictor of lower adjusted rates of death (2% versus 5.3%; p = 0.03, and 0% versus 3.5%, p = 0.004, respectively) and death or MI (3.1% versus 7.2%; p = 0.02, and 0% versus 4.5%, p<0.001, respectively) among patients with DES at 24 months; whereas patients who received BMS demonstrated no differences in these outcomes at 12-and 24-month follow-up. These data suggest that extended clopidogrel therapy can reduce the incidence of late thrombotic events in patients who have DES placement.…”

Section: Prevention Of Late Stent Thrombosis With Drug-eluting Stent mentioning

confidence: 99%

Clinical Considerations with the Use of Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention

et al. 2008

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Despite the proven benefits of using antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI), a number of key questions remain to be answered. In recent years, clopidogrel dosing strategies among such patients have evolved considerably, with newer approaches involving loading doses prior to PCI and increases in the time interval and loading dosage in an effort to overcome variable responsiveness/hyporesponsiveness to platelet inhibition. Further, the role of glycoprotein (GP) IIb/IIIa antagonists in elective stenting continues to be defined, with recent evidence suggesting that most appropriate use of these agents is in high‐risk patients with elevated troponin levels. There appears to be a relationship between the use of GP IIb/IIIa antagonists with clopidogrel loading and attenuation of early inflammatory and cardiac marker release. Strategies to minimize the chance of late stent thrombosis in patients who receive drug‐eluting stents (DES) are also under intense investigation. Among some patients receiving sirolimus and paclitaxel DES, current standard long‐term antiplatelet strategies may be insufficient. Patient nonadherence to treatment and premature discontinuation and underutilization of antiplatelet therapies by physicians remain important clinical problems with potentially dire consequences. Copyright © 2008 Wiley Periodicals, Inc.

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Late Clinical Events After Clopidogrel Discontinuation May Limit the Benefit of Drug-Eluting Stents

Abstract: After the discontinuation of clopidogrel, the benefit of DES in reducing target vessel revascularization is maintained but has to be balanced against an increase in late cardiac death or nonfatal MI, possibly related to late stent thrombosis.

Cited by 1,227 publications

References 43 publications

Patterns of antiplatelet drug use after a first myocardial infarction during a 10‐year period

Patterns of antiplatelet drug use after a first myocardial infarction during a 10‐year period

Cutting Balloon Angioplasty and Stent Implantation for Aorto‐ostial Lesions: Clinical Outcome and 1‐year Follow‐up

Clinical Considerations with the Use of Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention

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