Abstract 40: Hospital Variation in Premature Clopidogrel Discontinuation following Drug Eluting Stent Placement and Adverse Cardiovascular Outcomes from the VA Clinical Assessment, Reporting, and Tracking System for Cath Labs (CART-CL)

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Rebecca Vigen ◽  
Thomas M Maddox ◽  
Colin O'Donnell ◽  
Deepak L Bhatt ◽  
Thomas T Tsai ◽  
...  
Keyword(s):  
Tracking System ◽  
Adverse Outcomes ◽  
Drug Eluting Stents ◽  
Drug Eluting Stent ◽  
Hospital Level ◽  
Pharmacy Refill ◽  
Hospital Variation ◽  
Increased Risk ◽  
Drug Eluting ◽  
Clopidogrel Therapy

Background: Clopidogrel is recommended for 1 year following drug eluting stent (DES) placement and premature discontinuation has been associated with adverse outcomes. The extent of variation in premature discontinuation across hospitals within an integrated healthcare system is unknown. Accordingly, we assessed variation in premature clopidogrel discontinuation across all VA PCI sites and whether there was an association between hospitals with higher rates of premature discontinuation and adverse outcomes. Methods: We used the VA CART-CL registry which includes all PCIs with drug eluting stents performed between 10/01/08 and 09/30/09 at 55 VA cath labs that used CART. We evaluated the frequency of patients who prematurely discontinue clopidogrel at 6 and 9 months using pharmacy refill data. Multivariable regression assessed the association between premature discontinuation and all-cause mortality and/or myocardial infarction (MI). We then grouped sites into quartiles of premature discontinuation and evaluated the association between hospital level premature discontinuation and adverse outcomes. Results: Of the 7,022 patients who received a DES, 6.3% discontinued by 6 months, and 10.2% by 9 months. After risk adjustment, patients who discontinued clopidogrel prematurely had increased risk of adverse events with HR of 5.42 at 6 months (95% CI 4.22 – 6.99), and 6.24 at 9 months (95% CI 4.98 – 7.83). There was a significant trend in the unadjusted rates within quartiles toward increased risk of adverse outcomes among hospitals with greater rates of patients who discontinue prematurely by 6 months (p < 0.01 for trend, OR 1.65 CI 1.07 – 2.62 for comparison between quartile 1 and 4). Conclusion: Premature discontinuation of clopidogrel is associated with adverse outcomes among patients who receive drug eluting stents. Hospitals with higher rates of premature discontinuation of clopidogrel have higher rates of adverse outcomes. Hospital-level interventions to reduce early discontinuation of clopidogrel therapy have the potential to improve outcomes of patients who receive a DES.

Abstract 561: A Novel Integrin Modulating Arg-Gly-Asp(RGD)-Peptide-Coated Stent Reduces Neoatherosclerosis in a Rabbit Model

2015 ◽  
Vol 35 (suppl_1) ◽  
Author(s):  
Liang Guo ◽  
Tobias Koppara ◽  
Qi Cheng ◽  
Eduardo Acampado ◽  
Frank D Kolodgie ◽  
...  
Keyword(s):  
Thrombus Formation ◽  
Rabbit Model ◽  
Bare Metal Stents ◽  
Drug Eluting Stents ◽  
Drug Eluting Stent ◽  
Metal Stents ◽  
Cholesterol Diet ◽  
Increased Risk ◽  
Drug Eluting ◽  
Low Cholesterol

Objective: While drug-eluting stents have dramatically reduced restenosis, they are often associated with increased risk of late stent thrombosis and neointimal atherosclerosis (“neoatherosclerosis”). In-stent neoatherosclerosis represents a further accelerated and possibly more unstable manifestation of atherosclerotic progression in nascent neointimal tissue after stent implantation. We hypothesized that poor arterial re-endothelialization accompanied by leaky endothelial junctions is a primary mechanism contributing to neoatherosclerosis. In the present study, we tested the ability of a RGD-peptidomimetic-coating of bare metal stents to reduce the formation of in-stent neoatherosclerosis by promoting integrin-mediated adhesion of endothelial cells, and improving their functional integrity. Approach and Results: Established iliofemoral plaques were created in male New Zealand white rabbits (n=10) by balloon injury and feeding a high cholesterol (1.0%) diet for 5 wks, which was then switched to a low cholesterol diet (0.025%) for the remainder of the study. At 3 wks after diet switch, an RGD-coated stent was implanted together with a drug-eluting stent in the contralateral iliac artery, and animals were continued on the low cholesterol diet for 7 wks (serum cholesterol between 400-1,000 mg/dl). Endothelial permeability was assessed by FITC-dextran (250/500 kDa, approx. LDL radius) injected intravenously 1 h before termination. Oil red O and Filipin staining demonstrated neutral lipid and free cholesterol accumulation in the developing neointimal of stented arteries. En face confocal microscopy of the luminal surface following immunostaining against endothelial markers followed by scanning electron microscopy showed greater endothelial coverage of luminal surfaces for RGD-coated stents. Stents were further quantified by histomorphometric analysis for vascular healing, thrombus formation and inflammation. Conclusion: A rabbit neoatherosclerosis model was established to study the formation and progression of this novel disease manifestation. RGD-coated stents showed reduced formation of neoatherosclerosis in association with improved vessel healing and re-endothelialization compared to drug-eluting stents.

scholarly journals Increased Risk of Bleeding in Patients on Clopidogrel Therapy After Drug-Eluting Stents Implantation

2010 ◽  
Vol 3 (3) ◽  
pp. 230-235 ◽  
Author(s):  
Thomas T. Tsai ◽  
P. Michael Ho ◽  
Stanley Xu ◽  
J. David Powers ◽  
Nikki M. Carroll ◽  
...  
Keyword(s):  
Drug Eluting Stents ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Drug Eluting ◽  
Clopidogrel Therapy

Comparative Efficacy and Safety of Duration of Dual Antiplatelet Therapy in Patients with CAD Undergoing Drug-eluting Stent Implantation: A Systematic Review and Network Meta-analysis

2020 ◽  
Vol 26 (44) ◽  
pp. 5739-5745
Author(s):  
Jieqiong Guan ◽  
Wenjing Song ◽  
Pan He ◽  
Siyu Fan ◽  
Hong Zhi ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Major Bleeding ◽  
Dual Antiplatelet Therapy ◽  
Meta Analysis ◽  
Cochrane Library ◽  
Drug Eluting Stent ◽  
Efficacy And Safety ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Drug Eluting

Objective: The aim was to evaluate the efficacy and safety of duration of dual antiplatelet therapy (DAPT) for patients who received percutaneous coronary intervention (PCI) with a drug-eluting stent. Background: The optimal duration of DAPT to balance the risk of ischemia and bleeding in CAD patients undergoing drug-eluting stent (DES) implantation remains controversial. Methods: PubMed, Cochrane Library, Web of Science, Clinicaltrials.gov, CNKI and Wanfang Databases were searched for randomized controlled trials of comparing different durations of DAPT after DES implantation. Primary outcomes were major adverse cardiac and cerebrovascular events (MACCE), and major bleeding, and were pooled by Bayes network meta-analysis. Net adverse clinical and cerebral events were used to estimate the surface under the cumulative ranking (SUCRA) curves. The subgroup analysis based on clinical status, follow-up and area was conducted using traditional pairwise meta-analysis. Results: A total of nineteen trials (n=51,035) were included, involving six duration strategies. The network metaanalysis showed that T2 (<6-month DAPT followed by aspirin, HR:1.51, 95%CI:1.02-2.22), T3 (standard 6-month DAPT, HR:1.47, 95%CI:1.14-1.91), T4 (standard 12-month DAPT, HR:1.41, 95%CI:1.15-1.75) and T5 (18-24 months DAPT, HR:1.47, 95%CI:1.09-1.97) was associated with significantly increased risk of MACCE compared to T6 (>24-month DAPT). However, no significant difference was found in MACCE risk between T1 (<6-month DAPT followed by P2Y12 monotherapy) and T6. Moreover, T5 was associated with significantly increased risk of bleeding compared to T1(RR:3.94, 95%CI:1.66-10.60), T2(RR:3.65, 95%CI:1.32-9.97), T3(RR:1.93, 95%CI:1.21-3.50) and T4(RR:1.89, 95%CI:1.15-3.30). The cumulative probabilities showed that T6(85.0%), T1(78.3%) and T4(44.5%) were the most efficacious treatment compared to the other durations. In the ACS (<50%) subgroup, T1 was observed to significantly reduce the risk of major bleeding compared to T4, but not in the ACS (≥50%) subgroup. Conclusions: Compared with other durations, short DAPT followed by P2Y12 inhibitor monotherapy showed non-inferiority, with a lower risk of bleeding and not associated with an increased MACCE. In addition, the risk of major bleeding increased significantly, starting with DAPT for 18-month. Compared with the short-term treatment, patients with ACS with the standard 12-month treatment have a better prognosis, including lower bleeding rate and the decreased risk of MACCE. Due to study's limitations, the results should be verified in different risk populations.

Rapid adoption of drug-eluting stents: Clinical practices and outcomes from the early drug-eluting stent era

2010 ◽  
Vol 160 (4) ◽  
pp. 767-774.e1 ◽  
Author(s):  
John J. Lopez ◽  
Michelle J. Keyes ◽  
Sandeep Nathan ◽  
Robert Piana ◽  
Michael Pencina ◽  
...  
Keyword(s):  
Drug Eluting Stents ◽  
Drug Eluting Stent ◽  
Clinical Practices ◽  
Drug Eluting ◽  
Early Drug

Drug-eluting stents for drug-eluting stent restenosis

2014 ◽  
Vol 25 (8) ◽  
pp. 633-635
Author(s):  
Sebastian Kufner ◽  
Adnan Kastrati
Keyword(s):  
Drug Eluting Stents ◽  
Drug Eluting Stent ◽  
Stent Restenosis ◽  
Drug Eluting

Abstract 4486: Stent Thrombosis After Drug-Eluting Stent Implantation: Incidence, Timing and Relation to Discontinuation of Clopidogrel Therapy Over a 4-Year Period

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Stefanie Schulz ◽  
Julia Ellert ◽  
Julia Goedel ◽  
Robert A Byrne ◽  
Raisuke Iijma ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Cumulative Incidence ◽  
High Volume ◽  
Coronary Intervention ◽  
Drug Eluting Stent ◽  
Time Interval ◽  
Number Of Patients ◽  
Drug Eluting ◽  
Clopidogrel Therapy ◽  
Observational Cohort

To assess the incidence, timing and relation of drug-eluting stent thrombosis (ST) to discontinuation of clopidogrel therapy. This prospective observational cohort study includes 6816 consecutive patients that underwent a successful drug-eluting stent (DES) implantation between July 2002 through December 2006 in 2 tertiary, high-volume percutaneous coronary intervention (PCI) centers in Germany. The primary end point was definite ST (ARC definition). During 4-year follow-up, 4.2% of the patient population incurred a myocardial infarction (MI), 8.6% had died and 3.1% had experienced a bleeding complication. Definite ST was observed in 73 patients, corresponding to a cumulative incidence of 1.2% at 4 years. Cumulative incidence of ST was 0.5% at 30 days and 0.8% at 1 year. In comparison to patients without ST, patients with ST carried a higher risk of MI (93% versus 3%; OR 48.5 [41.3 to 57.1]) and death (42% versus 8%; OR 5.2 [3.6 to 7.6]). Figure 1 shows the number of patients with ST in each time interval from discontinuation of clopidogrel therapy. Figure 2 depicts the cumulative incidence of ST in patients who were on clopidogrel therapy and in those who discontinued clopidogrel. The 4-year incidence of ST after DES implantation is low in high-volume PCI centers. A relevant number of ST occur early after discontinuation of clopidogrel therapy. The dependence of ST on discontinuation of clopidogrel therapy is evident during the first 6 months but not thereafter.

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