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Best use of drug-eluting stents
September 02, 2008When should they be avoided?
Compared with bare metal stents, drug-eluting stents substantially reduce the risk of angiographic and clinical recurrence but do not affect mortality or the short term or long term risk of myocardial infarction. The use of drug-eluting stents necessitates extended treatment with dual antiplatelet therapy (aspirin plus thienopyridine) which may cause bleeding complications and interferes with or even precludes surgery in case this is needed.
In addition, from a socioeconomic standpoint, the increased cost associated with drug-eluting stents is a major issue.
Based on these considerations, drug-eluting stents should be avoided (a) when the expected benefit is low and (b) when the risk associated with extended dual antiplatelet therapy is high.
After placement of bare metal stents, the risk of restenosis varies considerably based on patient and lesion characteristics. Specifically, patients who do not suffer from diabetes have a substantially lower risk than diabetic patients. Strong lesion-specific predictors of a low risk of restenosis after bare metal stents include short lesion length and large vessel size. Thus, in non-diabetic patients with a short lesion in a large vessel, the risk of restenosis after placement of a bare metal stent is below 10 %. In these subsets, a substantial benefit from drug-eluting stents cannot be expected. These considerations are confirmed by data from randomized studies as well as from registries.
In patients with bleeding disorders, the risk of bleeding complications during dual antiplatelet therapy is particularly high. On the other hand, premature discontinuation of dual antiplatelet therapy for imminent or overt bleeding carries a substantial risk of stent thrombosis with potentially fatal outcome. A particularly difficult patient subset in this respect concerns those in need for anticoagulation, such as patients with atrial fibrillation at high risk for thromboembolic events or patients with prosthetic valve replacement. In these patients, interventional cardiologists are well advised to use a bare metal stent to keep the need for dual antiplatelet therapy as short as possible.
Drug-eluting stents should also be avoided in patients with planned surgical procedure and in those likely to undergo a surgery within the next year.
European Society of Cardiology
Based on these considerations, drug-eluting stents should be avoided (a) when the expected benefit is low and (b) when the risk associated with extended dual antiplatelet therapy is high.
After placement of bare metal stents, the risk of restenosis varies considerably based on patient and lesion characteristics. Specifically, patients who do not suffer from diabetes have a substantially lower risk than diabetic patients. Strong lesion-specific predictors of a low risk of restenosis after bare metal stents include short lesion length and large vessel size. Thus, in non-diabetic patients with a short lesion in a large vessel, the risk of restenosis after placement of a bare metal stent is below 10 %. In these subsets, a substantial benefit from drug-eluting stents cannot be expected. These considerations are confirmed by data from randomized studies as well as from registries.
In patients with bleeding disorders, the risk of bleeding complications during dual antiplatelet therapy is particularly high. On the other hand, premature discontinuation of dual antiplatelet therapy for imminent or overt bleeding carries a substantial risk of stent thrombosis with potentially fatal outcome. A particularly difficult patient subset in this respect concerns those in need for anticoagulation, such as patients with atrial fibrillation at high risk for thromboembolic events or patients with prosthetic valve replacement. In these patients, interventional cardiologists are well advised to use a bare metal stent to keep the need for dual antiplatelet therapy as short as possible.
Drug-eluting stents should also be avoided in patients with planned surgical procedure and in those likely to undergo a surgery within the next year.
European Society of Cardiology
Antiplatelet Therapy Current Events and Antiplatelet Therapy News RSSTriple antiplatelet therapy appears superior to dual antiplatelet therapy
Results of five research studies and a clinical registry first-report presentation scheduled for the 20th annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium, sponsored by the Cardiovascular Research Foundation (CRF), suggest that triple antiplatelet therapy for patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents achieves greater platelet inhibition than conventional dual antiplatelet therapy.
Study Finds Half of Patients Undergoing Cerebrovascular Stent Placement Respond Poorly to the Antiplatelet Drug Clopidogrel (Plavix)
A study by researchers at Rush University Medical Center, published in the February issue of the American Journal of Neuroradiology, finds that half of patients undergoing cerebrovascular stent placement did not respond well to clopidogrel. Clopidogrel (Plavix) and aspirin are medications routinely prescribed for 1-3 months following cerebrovascular stent placement to combat the risk of blood clots (stent-thrombosis) and reclosure of the artery (re-stenosis).
Increased risk of heart attack or stroke for patients who are resistant to aspirin
Being resistant to aspirin makes patients four times more likely to suffer a heart attack, stroke or even die from a pre-existing heart condition, according to a study published on bmj.com today.
Value of stent-coating drugs questioned
Patients admitted to the hospital with acute coronary syndromes (ACS) are often treated with a catheter-based procedure known as percutaneous coronary intervention (PCI), during which a stent is inserted into an occluded or narrowed coronary artery to restore blood flow to and from the heart.
Patients who receive drug-eluting stents should continue antiplatelet medications
Patients who have had drug-eluting stents inserted to prop open blocked coronary arteries should continue to take medications to reduce the risk of blood clots for at least one year after the stent is inserted, a new scientific advisory recommends.
New generation of cardiac interventions, therapies optimize heart disease care
Research presented today at the American College of Cardiology's 55th Annual Scientific Session and the inaugural Innovation in Intervention: i2 Summit 2006 in Atlanta, Ga., highlights critical advances in the treatment of cardiovascular disease.
Atherothrombosis patients world-wide often have undertreated, undercontrolled risk factors
A large international study demonstrates that patients world-wide with atherothrombosis (coronary artery disease, cerebrovascular disease, peripheral arterial disease) often have cardiovascular risk factors such as obesity and hypertension that are undertreated and undercontrolled.
Dipyridamole, ASA and warding off stroke
In this article, Dr. Cathie Sudlow, one of the investigators in a major randomized controlled clinical trial of antiplatelet therapy for stroke and myocardial infarction in high risk patients, comments on the recent decision by the influential U.K National Institute for Heath and Clinical Excellence (NICE) to recommend that dipyridamole be recommended in addition to ASA.
Part of drug trial for patients with atrial fibrillation discontinued
Study treatments for the ACTIVE W trial of the ACTIVE (Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events) program have been discontinued due to a significant difference in efficacy, in favour of the standard oral anticoagulation (OAC) over antiplatelet therapy (clopidogrel plus aspirin).
Early reports of thrombosis after insertion of drug-eluting stent (pp 1466, 1519)
Authors of a research letter in this week's issue of THE LANCET highlight how the use of drug-eluting stents (DES) may carry a risk of subsequent thrombosis if stenting is accompanied by a withdrawal of antiplatelet therapy.
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