Predictors of Impaired Reperfusion after Percutaneous Coronary Intervention in Patients with In-Hospital Acute Stent Thrombosis: A Retrospective Analyses of 5 Years of Data

BACKGROUND

Acute stent thrombosis (STh) is a rare complication of percutaneous coronary intervention (PCI) and is associated with a high-risk of reperfusion failure. However, data focusing on risk factors of reperfusion failure in patients undergoing repeat PCI for treatment of STh remains inadequate.

METHODS

A total of 8815 patients who underwent PCI with stent implantation from January 2009 to December 2013 were retrospectively reviewed. Among those cases, patients that presented with acute STh and underwent a repeat PCI for acute STh were identified.

RESULTS

There were 108 patients who underwent repeat PCI for the treatment of in-hospital acute STh that were retrospectively analyzed. Of these study subjects, 21 (25%) had thrombolysis in myocardial infarction (TIMI) flow < 3 after repeat PCI. The median value of pain-to-balloon time was 40 minutes in the TIMI < 3 group, 35 minutes in the TIMI = 3 group (p < 0.001), and the first PCI-to-stent thrombosis time was also longer in the TIMI < 3 group (10 hours vs. 2.5 hours, p = 0.001). When patients were evaluated according to PCI time, the percentage of patients with TIMI < 3 was significantly higher in the night period compared to the daytime period (46.4% vs. 17.5 %, p = 0.002). In the multivariable logistic regression analysis, stent length [odds ratio (OR) = 1.18, 95% confidence interval (CI) 1.008-1.38] and pain-to- balloon time (OR = 1.28, 95% CI, 1.06-1.54) were the only independent predictors of failed reperfusion.

CONCLUSIONS

Baseline stent length and pain-to-balloon time were associated with reperfusion failure in PCI for STh. Moreover, TIMI flow grade showed a circadian variation.

Adherence to antiplatelet treatment with P2Y12 receptor inhibitors. Is there anything we can do to improve it? A systematic review of randomized trials

Antiplatelet therapy is the cornerstone of treatment for patients with acute coronary syndromes (ACS) and/or undergoing percutaneous coronary interventions. Non-adherence to medication after ACS may lead to increased morbidity, mortality, and costs to the healthcare system due to elevated risk of stent thrombosis, myocardial infarction or death. Medication adherence is an issue of growing concern regarding the improvement of health system performance. Promoting medication adherence offers a rare opportunity to simultaneously improve health outcomes while reducing costs of treatment in patients with coronary artery disease (CAD). The aim of this systematic review was to critically discuss adherence to antiplatelet treatment with P2Y12 receptor inhibitors in CAD patients. After a systematic investigation of the literature in databases including PubMed, CENTRAL and Google Scholar, using appropriate keywords, and considering clinical randomized, prospective observational and retrospective studies, reporting on adherence to treatment with inhibitors of P2Y12 platelet receptors or educational interventions aimed to improve medication adherence in patients with CAD, seven articles were considered eligible for inclusion in this systematic review. Reported adherence to clopidogrel, despite catastrophic consequences of its premature discontinuation, is low. We identified several determinants of low adherence and early discontinuation of clopidogrel. We also present data on the usefulness, utilization and credibility of different methods of medication adherence assessment, and suggest and critically discuss available interventions aimed at improvement of adherence to clopidogrel, still showing the need for innovative approaches to achieve enhanced medication adherence and improve health outcomes after acute myocardial infarction.

Incidence, Implications, and Predictors of Stent Thrombosis in Acute Myocardial Infarction

Stent thrombosis (ST) remains a catastrophic problem in patients undergoing percutaneous coronary intervention (PCI). However, a paucity of data exist regarding the incidence, implications, and predictors of ST in patients with acute myocardial infarction (AMI). We consecutively enrolled patients with AMI in the CardiOvascular Risk and idEntificAtion of potential high-risk population in AMI registry who underwent PCI from January 2004 to December 2009 and analyzed definite or probable ST according to Academic Research Consortium definitions. The median follow-up duration was 41.9 months. Definite or probable ST occurred in 136 patients (3.7%), including 44 with early ST (1.0%), 38 with late ST (0.9%), and 54 with very late ST (2.0%). The annual incidence of very late ST ranged from 0.5% to 0.6%. The all-cause mortality rate after ST was 29%, which was higher than that for patients without ST (17%; p <0.001). The independent predictors of ST were no-reflow phenomenon (hazard ratio [HR] 1.96, 95% confidence interval [CI] 1.28 to 3.03), decreased left ventricular ejection fraction (HR 1.70, 95% CI 1.21 to 2.40), anemia (HR 1.54, 95% CI 1.09 to 2.18), and a mean stent diameter <3.0 mm (HR 1.53, 95% CI 1.04 to 2.27). ST is not uncommon in patients with AMI and continues to occur beyond 1 year after PCI, irrespective of the stent type or clinical presentation. Patients with ST are associated with higher mortality than patients without ST. No reflow, decreased left ventricular ejection fraction, anemia, and a mean stent diameter <3.0 mm are independent predictors of ST.

Relation between stent thrombosis and calcium channel blocker after drug-eluting stent implantation: Kumamoto Intervention Conference Study (KICS) registry

BACKGROUND

Stent thrombosis (ST) has emerged as a severe complication of percutaneous coronary intervention (PCI). Since the occurrence of ST is lower in Japan than Western countries, there are few data to predict ST after drug-eluting stent (DES) implantation in Japan. We examined the independent predictors of ST incidence after DES implantation in Japanese patients, including the use of calcium channel blockers (CCBs).

METHODS AND RESULTS

We used data from the Kumamoto Intervention Conference Study registry. There were 6286 consecutive patients enrolled from June 2008 to March 2011. Among them, we analyzed 3493 patients who underwent DES implantation. The incidence of definite/probable ST throughout a median follow-up period of 364 days was 0.57% (20 patients). There were 8 patients with early ST (within 30 days), 8 patients with late ST (between 31 and 365 days), and 4 patients with very late ST (after 1 year). The frequency of CCB use was significantly lower in ST than non-ST patients (25.0% versus 51.4%, respectively, p=0.016). Multiple regression analysis showed that longer stent length (p=0.034), acute coronary syndrome (p=0.039), and the absence of CCB use (p=0.046) were significant and independent predictors of ST within 1 year.

CONCLUSIONS

These results suggest that CCB use may be associated with a decreased risk of ST after DES implantation within 1 year in Japanese patients.