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CLINICAL STUDY: INTERVENTIONAL CARDIOLOGY

Incidence of thrombotic occlusion and major adverse cardiac events between two and four weeks after coronary stent placement: analysis of 5,678 patients with a four-week ticlopidine regimen

Helmut Schühlen, MD, FESC^*, Adnan Kastrati, MD, FESC, J.ürgen Pache, MD, Josef Dirschinger, MD and Albert Schömig, MD

^* Medizinische Klinik, Klinikum rechts der Isar, Munich, Germany
Deutsches Herzzentrum, Technische Universität, Munich, Germany

Manuscript received October 15, 2000; revised manuscript received February 20, 2001, accepted March 1, 2001.

Reprint requests and correspondence: Dr. Helmut Schühlen, Medizinische Klinik, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Germany
h.schuehlen{at}med1.med.tu-muenchen.de

OBJECTIVES

We attempted to make a comprehensive assessment of the risk of stent failure (death, myocardial infarction or angiographically documented occlusion), differentiating early (first and second weeks) and late (third and fourth weeks) events.

BACKGROUND

The risk of stent failure decreases rapidly within the first week. It has been suggested that the risk rate for late events is close to 0% and that the thienopyridine regimen (ticlopidine or clopidogrel) could be safely reduced from four to two weeks, minimizing the risk of hematological complications.

METHODS

We analyzed 5,678 patients with successful coronary stent placement and a four-week ticlopidine regimen.

RESULTS

The rate of stent failure was 2.5% at four weeks, with 112 early (2.0%) and 30 late events (0.5%). Multivariate analysis identified different risk factors for early versus late events. While variables on stenosis severity and procedural results that can be influenced by the operator were identified as independent risk factors for early events (percent stenosis before and after the procedure, residual dissection, length of stented segment), more clinical variables were associated with late events (age, reduced left ventricular function, systemic hypertension as a protective factor). The late-event rate was <0.1% in the absence of these factors, but it was 2.5% with all three risk factors present.

CONCLUSIONS

The risk of late stent failure is low with a four-week ticlopidine regimen. However, high-risk subgroups have a risk of 2.5%. As this rate is presumably higher if thienopyridines are discontinued after two weeks, these data suggest that a risk stratification to a two- or four-week regimen is preferable to a general reduction.

Abbreviations and Acronyms   ATLAST = Antiplatelet Therapy versus Antiplatelet Therapy Alone in Patients at Increased Risk of Stent Thrombosis trial   CART = classification and regression tree   FANTASTIC = Full Anticoagulation Versus Aspirin and Ticlopidine study   ISAR = Intracoronary Stenting and Antithrombotic Regimen trial   LV = left ventricle or left ventricular   MATTIS = Multicenter Aspirin and Ticlopidine Trial after Intracoronary Stenting   MI = myocardial infarction

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