Stent Thrombosis Risk Over Time on the Basis of Clinical Presentation and Platelet Reactivity: Analysis From ADAPT-DES

Katherine H Chau; Ajay J Kirtane; Rachel M Easterwood; Björn Redfors; Zixuan Zhang; Bernhard Witzenbichler; Giora Weisz; Thomas D Stuckey; Bruce R Brodie; Michael J Rinaldi; Franz-Josef Neumann; D Christopher Metzger; Timothy D Henry; David A Cox; Peter L Duffy; Ernest L Mazzaferri Jr; Roxana Mehran; Gregg W Stone

doi:10.1016/j.jcin.2020.12.005

Stent Thrombosis Risk Over Time on the Basis of Clinical Presentation and Platelet Reactivity: Analysis From ADAPT-DES

JACC Cardiovasc Interv. 2021 Feb 22;14(4):417-427. doi: 10.1016/j.jcin.2020.12.005. Epub 2021 Jan 27.

Authors

Katherine H Chau¹, Ajay J Kirtane², Rachel M Easterwood³, Björn Redfors⁴, Zixuan Zhang³, Bernhard Witzenbichler⁵, Giora Weisz¹, Thomas D Stuckey⁶, Bruce R Brodie⁶, Michael J Rinaldi⁷, Franz-Josef Neumann⁸, D Christopher Metzger⁹, Timothy D Henry¹⁰, David A Cox¹¹, Peter L Duffy¹², Ernest L Mazzaferri Jr¹³, Roxana Mehran¹⁴, Gregg W Stone¹⁵

Affiliations

¹ Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA.
² Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA. Electronic address: akirtane@columbia.edu.
³ Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.
⁴ Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Herbert and Sandi Feinberg Interventional Cardiology and Heart Valve Center at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
⁵ Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau, Germany.
⁶ LeBauer-Brodie Center for Cardiovascular Research and Education/Cone Health, Greensboro, North Carolina, USA.
⁷ Sanger Heart & Vascular Institute/Atrium Health, Charlotte, North Carolina, USA.
⁸ Division of Cardiology and Angiology II, Heart Center University of Freiburg, Bad Krozingen, Germany.
⁹ Ballad Health CVA Heart Institute, Kingsport, Tennessee, USA.
¹⁰ Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA; The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA.
¹¹ CVA Brookwood Baptist Hospital, Birmingham, Alabama, USA.
¹² Appalachian Regional Healthcare System, Boone, North Carolina, USA.
¹³ The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
¹⁴ Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
¹⁵ Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address: https://twitter.com/GreggWStone.

PMID: 33516690
DOI: 10.1016/j.jcin.2020.12.005

Abstract

Objectives: The aim of this study was to determine the risk period for increased stent thrombosis (ST) after percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) and whether this increased risk is related to high platelet reactivity (HPR).

Background: ST risk after PCI is higher among patients with ACS than those with stable ischemic heart disease. When ST risk is highest in patients with ACS and how that is affected by HPR is unknown.

Methods: Using the ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) registry, ST rates during 2-year follow-up post-PCI with drug-eluting stents were compared among patients presenting with ACS (myocardial infarction [MI] or unstable angina) or stable ischemic heart disease (non-ACS). Landmark analyses were done at 30 days and 1 year post-PCI. Platelet reactivity on aspirin and clopidogrel post-PCI was assessed using VerifyNow assays.

Results: Of 8,582 patients, 2,063 presented with MI, 2,370 with unstable angina, and 4,149 with non-ACS. Incidence rates of HPR were 48.0%, 43.3%, and 39.8%, respectively (p < 0.001). Within the first 30 days post-PCI, patients presenting with MI had increased ST risk compared with patients with non-ACS (hazard ratio [HR]: 4.52; 95% confidence interval [CI]: 2.01 to 10.14; p < 0.001). After 30 days, relative ST risks were progressively lower and no longer significant between groups (31 days to 1 year post-PCI: HR: 1.97; 95% CI: 0.80 to 4.85; >1 year post-PCI: HR: 0.89; 95% CI: 0.27 to 2.92). The elevated ST risk in patients with MI within 30 days was largely confined to those with HPR on clopidogrel (HR: 5.77; 95% CI: 2.13 to 15.63; p < 0.001).

Conclusions: Among patients undergoing PCI, rates of ST during 2-year follow-up were highest in those with MI and lowest in those with non-ACS. Increased ST risk in patients with MI was greatest in the first 30 days post-PCI and was observed predominantly among those with increased HPR on clopidogrel. These findings emphasize the importance of adequate P2Y₁₂ inhibition after MI, especially within the first 30 days after stent implantation.

Keywords: acute coronary syndrome(s); antiplatelet therapy; platelet reactivity; stent thrombosis.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Drug-Eluting Stents*
Humans
Percutaneous Coronary Intervention* / adverse effects
Platelet Aggregation Inhibitors / adverse effects
Risk Factors
Thrombosis* / diagnostic imaging
Thrombosis* / epidemiology
Thrombosis* / etiology
Treatment Outcome

Substances

Platelet Aggregation Inhibitors