Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
Am J Cardiol. 2014 Jun 15;113(12):1968-76. doi: 10.1016/j.amjcard.2014.03.041. Epub 2014 Apr 1.
Premature antiplatelet therapy discontinuation (ATD) after drug-eluting stent (DES) implantation is known to predict stent thrombosis (ST). However, recent data suggest that a shorter antiplatelet therapy duration is safe with newer generation DESs. The study aimed to compare the impact of early and late clopidogrel ATDs on ST in a real-world registry of first- and second-generation DES use. A total of 6,236 patients who underwent DES implantation were analyzed retrospectively: 4,217 received first-generation DESs (sirolimus- and paclitaxel-eluting stents) and 2,019 received second-generation DESs (everolimus-eluting stents). Within each DES cohort, patients were categorized into timing of clopidogrel discontinuation within 1 year: early (<3 months), late (3 to 12 months), and continued. ST rates and clinical outcomes at 1 year were analyzed. There were 341 patients (8.1%) in the first-generation DES group and 126 patients (6.2%) in the second-generation DES group who discontinued clopidogrel within the first year. Definite and probable ST rates were 3.8% for early ATD, 2.5% for late ATD, and 0.5% for continued (p = 0.001) in the first-generation DES cohort, whereas there were no definite or probable ST events in early and late ATDs and 0.5% for continued in the second-generation DES cohort. Major adverse cardiac event rates were 9.9% for early ATD, 5.6% for late ATD, and 0.9% for continued (p <0.001) in the first-generation DES cohort and 5.5% for early ATD, 7.4% for late ATD, and 1.5% for continued (p <0.001) in the second-generation DES cohort. In conclusion, ATD within the first year is associated with increased ST events with first-generation DESs, whereas ATD appears safe with second-generation DESs with regard to ST. However, ATD is associated with greater mortality and major adverse cardiac events in both first- and second-generation DESs. Thus, this study supports ATD if required based on physician discretion with the use of second-generation DESs but cannot rule out potential benefit for longer duration of dual antiplatelet therapy even when second-generation DESs are used.
在药物洗脱支架 (DES) 植入后过早停止抗血小板治疗 (ATD) 已知可预测支架血栓形成 (ST)。然而，最近的数据表明，使用新一代 DES 进行更短时间的抗血小板治疗是安全的。本研究旨在比较第一代和第二代 DES 使用的真实世界登记研究中早期和晚期氯吡格雷 ATD 对 ST 的影响。回顾性分析了 6236 例接受 DES 植入的患者：4217 例接受第一代 DES（西罗莫司和紫杉醇洗脱支架），2019 例接受第二代 DES（依维莫司洗脱支架）。在每个 DES 队列中，根据氯吡格雷停药时间将患者分为 1 年内的时间点：早期（<3 个月）、晚期（3 至 12 个月）和持续。分析了 1 年时 ST 发生率和临床结局。第一代 DES 组有 341 例（8.1%）和第二代 DES 组有 126 例（6.2%）患者在 1 年内停用氯吡格雷。第一代 DES 队列中早期 ATD 的确定和可能 ST 发生率为 3.8%，晚期 ATD 为 2.5%，持续 ATD 为 0.5%（p=0.001），而第二代 DES 队列中早期和晚期 ATD 均无确定或可能的 ST 事件，持续 ATD 为 0.5%。第一代 DES 队列中早期 ATD 的主要不良心脏事件发生率为 9.9%，晚期 ATD 为 5.6%，持续 ATD 为 0.9%（p<0.001），第二代 DES 队列中早期 ATD 为 5.5%，晚期 ATD 为 7.4%，持续 ATD 为 1.5%（p<0.001）。总之，第一代 DES 中 1 年内的 ATD 与 ST 事件增加相关，而第二代 DES 中 ATD 似乎与 ST 相关安全。然而，第一代和第二代 DES 中，ATD 与死亡率和主要不良心脏事件增加相关。因此，本研究支持在使用第二代 DES 时根据医生的判断进行 ATD，但不能排除即使使用第二代 DES 时延长双联抗血小板治疗时间的潜在益处。
