Very Late Stent Thrombosis After Primary Percutaneous Coronary Intervention With Bare-Metal and Drug-Eluting Stents for ST-Segment Elevation Myocardial Infarction

Abstract

Objectives The purpose of this study was to assess the frequency of very late stent thrombosis (VLST) after stenting with bare-metal stents (BMS) and drug-eluting stents (DES) for ST-segment elevation myocardial infarction (STEMI). Background Stent thrombosis occurs more frequently after stenting for STEMI than after elective stenting, but there are little data regarding VLST. Methods Consecutive patients (n = 1,463) who underwent stenting for STEMI were prospectively enrolled in our database. BMS were implanted exclusively from 1995 to 2002, and DES and BMS were implanted from 2003 to 2009. Follow-up was obtained at 1 to 15 years. Results Bare-metal stent patients (n = 1,095) were older and had more shock, whereas DES patients (n = 368) had more diabetes and smaller vessels. Stent thrombosis occurred in 107 patients, of which 42 were VLST (>1 year). Stent thrombosis continued to increase to at least 11 years with BMS and to at least 4.5 years with DES. Stent thrombosis rates with BMS versus DES were similar at 1 year (5.1% and 4.0%, respectively) but increased more with DES after the first year (1.9%/year vs. 0.6%/year, respectively). Landmark analysis (>1 year) found DES had a higher frequency of VLST (p < 0.001) and reinfarction (p = 0.003). Drug-eluting stent was the only significant independent predictor of VLST (hazard ratio: 3.79, 95% confidence interval: 1.64 to 8.79, p = 0.002). Conclusions Very late stent thrombosis after primary PCI for STEMI occurs with relatively high frequency to at least 11 years with BMS and to at least 4.5 years with DES. Very late stent thrombosis and reinfarction (>1 year) were more frequent with DES. New strategies are needed to manage this problem.

Difference in Clinical and Angiographic Characteristics of Very Late Stent Thrombosis Between Drug-Eluting and Bare-Metal Stent Implantations

“…15, 16 In a previous study that was conducted after acute myocardial infarction, VLST was observed within 5 years of BMS implantation in a small number of patients. 17 We suggest 2 reasons for the differences between the previous and the present studies. First, the previous study was limited to patients with acute myocardial infarction, and therefore patient background may have led to the differences in the results.…”

Long-term outcomes of biodegradable versus durable polymer drug-eluting stents in patients with acute ST-segment elevation myocardial infarction: a pooled analysis of individual patient data from three randomised trials

“…Numerous reports have highlighted STEMI as a risk factor for late reinfarction and late stent thrombosis following primary intervention 3,4,20 . This is thought to be due to a combination of factors including adverse lesion morphology and high thrombus burden, persistent inflammation and increased platelet reactivity, as well as chronic processes associated with delayed healing and vessel remodelling 21 .…”

“…Patients with ST-segment elevation myocardial infarction (STEMI) have poorer outcomes after percutaneous coronary intervention (PCI) compared to those with stable coronary artery disease, with higher rates of stent thrombosis and increased risk of reinfarction persisting at long-term follow-up 3,4 . Although PCI with DES improves efficacy outcomes in patients with STEMI, maintenance of superior safety outcomes in the long term has not yet been conclusively demonstrated in comparison to BMS in STEMI, even for newer-generation DES [5][6][7][8] .…”

Primary Percutaneous Coronary Intervention and Risk of Stent Thrombosis

“…Along this line, observational studies have reported an increased risk of very late ST with DES compared with BMS among STEMI patients. 3,4 Second, none of the individual STEMI trials have been powered adequately to address infrequent adverse events, such as very late ST. Third, histopathological analysis of autopsy specimens revealed more inflammation, fibrin deposition, and uncovered struts among lesions treated with DES in STEMI patients compared with those with stable lesions, suggesting a differential arterial response to DES depending on underlying plaque morphology. 5 Fourth, late acquired stent malapposition (LASM) was more common among DES (31%) than BMS (8%, Pϭ0.02) 13 months after PCI in the Intravascular Ultrasound (IVUS) substudy of HORIZONS-AMI.…”