1. STENT THROMBOSIS: WHICH IMPACT IN REAL CLINICAL PRACTICE? Giuseppe Biondi Zoccai Divisione di Cardiologia, Università di Torino Ospedale S. Giovanni Battista “Molinette” Torino gbiondizoccai@gmail.com

2. 2 Learning goals What is stent thrombosis? Can I predict stent thrombosis? What is the real impact of stent thrombosis?

3. 3 Learning goals What is stent thrombosis? Can I predict stent thrombosis? What is the real impact of stent thrombosis?

4. 4 Failing stents: thrombosis vs restenosis Schuchman, New Engl J Med 2006

5. 5 Stent thrombosis in the medical literature Google Scholar searched for “stent AND thrombosis” on 8 June 2010

6. 6 History of stent thrombosis IMPACT OF DUAL ANTIPLATELET THERAPY AND HIGH PRESSURE DILATION

7. 7 Definition of stent thrombosis Acute occlusion of a previously patent stent It is a clinical syndrome (presents with acute coronary syndrome or sudden death – if silent cannot be defined stent thrombosis) It is not due to new plaque rupture at distant site There was no severe restenosis with final occlusion

8. 8 Academic Research Consortium definitions Definite: Clinical syndrome (ACS or AMI) and angiographic evidence of thrombus or occlusion or pathologic evidence of acute thrombosis Probable: Unexplained death < 30 days or target vessel AMI without angiographic confirmation of thrombosis or other identified culprit lesion Possible: Unexplained death after 30 days Cutlip et al, Circulation 2007

9. 9 Timing of stent thrombosis TypeOccurrence*Incidence Acute≤1 day+ Subacute2-30 days+++ Late2-12 months++ Very late>1 year++ *after PCI

10. 10 Learning goals What is stent thrombosis? Can I predict stent thrombosis? What is the real impact of stent thrombosis?

11. 11 Mechanisms of thrombosis: Virchow's triad BLOODFLOW VESSEL

12. 12 Mechanisms of stent thrombosis PATIENT FACTORS LESION FACTORS PROCEDURAL & MEDICAL RX FACTORS

13. 13 Genetic variability in risk of stent thrombosis Mega et al, New Engl J Med 2009

14. 14 Predicting thrombosis according to diabetes Machecourt et al, J Am Coll Cardiol 2009

15. 15 Predicting thrombosis according to stent length Moreno et al, J Am Coll Cardiol 2005

16. 16 What about late stent thrombosis? McFadden et al, Lancet 2004 €

17. 17 Impact of antiplatelet therapy discontinuation Kimura et al, Circulation 2009

18. 18 Impact of antiplatelet therapy intensity Mehta et al, ESC 2009 Clopidogrel 600+150 mg Clopidogrel 300+75 mg P Definite stent thrombosis0.7%1.2%0.002 Myocardial infarction2.0%2.6%0.012 Stroke0.4% 0.59 Cardiovascular death1.9% 0.68 Myocardial infarction or stent thrombosis 3.0%3.7%0.008 Cardiovascular death, myocardial infarction, or stroke 3.9%4.5%0.036 30-day results of the CURRENT-OASIS 7 Trial

19. 19 Predictors of drug-eluting stent thrombosis Iakovou et al, JAMA 2005

20. 20 Predictors of stent thrombosis after ACS Van Werkum et al, J Am Coll Cardiol 2009

21. 21 Any synthesis possible? Capodanno et al, Clin Res Cardiol 2009

22. 22 Any synthesis possible? Capodanno et al, Clin Res Cardiol 2009

23. 23 Learning goals What is stent thrombosis? Can I predict stent thrombosis? What is the real impact of stent thrombosis?

24. 24 Timing and incidence of stent thrombosis Stents Early stent thrombosis Late stent thrombosis Very late stent thrombosis SES vs BMS 1 0.5% vs 0.3%0.1% vs 1.0%0.9% vs 0.4% PES vs BMS 1 0.5% vs 0.5%0.4% vs 0.3%0.9% vs 0.6% ZES vs BMS 2 0.3% vs 1.2%0.3% vs 0.1%0.1% vs 0.1% EES vs PES 3 0.4% vs 00.3% vs 0.6%0.3% vs 1.0% 1 Mauri et al, New Engl J Med 2007 2 Leon, TCT 2008 3 Stone et al, Circulation 2009

25. 25 Incidence of stent thrombosis in Bern & Rotterdam Daemen et al, Lancet 2007

26. 26 Incidence of stent thrombosis in Sweden Lagerqvist et al, Circulation Int 2009

27. 27 Outlook after stent thrombosis Van Werkum et al, Circulation 2009

28. 28 Impact of BMS thrombosis Cutlip et al, Circulation 2001

29. 29 Impact of definite DES thrombosis Kuchulakanti et al, Circulation 2006

30. 30 Impact of definite or probable DES thrombosis Mauri et al, New Engl J Med 2007

31. 31 More on impact of DES thrombosis Daemen et al, Lancet 2007

32. 32 Stent thrombosis in further perspective Daemen et al, Lancet 2007

33. 33 Take home messages

34. 34 Take home messages Stent thrombosis is a clinically important event, causing often death or myocardial infarction in those experiencing it Stent thrombosis is however rare, but it can be predicted by patient and lesion factors, and modulated by procedural, pharmacologic and other treatment decisions Thus, when addressing the issue of stent thrombosis, it is crucial to individualize management strategies in order to maximize benefits and minimize risks

35. 35 Thank you for your attention For any correspondence: gbiondizoccai@gmail.com For these and further slides on these topics feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html