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ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction

ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease
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J Am Coll Cardiol, 2005; 46:1827-1832, doi:10.1016/j.jacc.2005.07.056 (Published online 18 October 2005).
© 2005 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: PLATELETS AND STENT THROMBOSIS

Clopidogrel Effect on Platelet REactivity in Patients With Stent Thrombosis

Results of the CREST Study

Paul A. Gurbel, MD, FACC*, Kevin P. Bliden, BS, Waiel Samara, MD, Jason A. Yoho, MD, Kevin Hayes, MD, Mulugeta Z. Fissha, MD and Udaya S. Tantry, PhD

Sinai Center for Thrombosis Research, Baltimore, Maryland.

Manuscript received December 22, 2004; revised manuscript received July 11, 2005, accepted July 19, 2005.

* Reprint requests and correspondence: Dr. Paul A. Gurbel, Sinai Center for Thrombosis Research, Hoffberger Building, Suite 56, 2401 West Belvedere Avenue, Baltimore, Maryland 21215. (Email: pgurbel{at}lifebridgehealth.org).

OBJECTIVES: We investigated whether patients who suffered subacute stent thrombosis (SAT) have higher post-treatment reactivity than those who do not encounter stent thrombosis.

BACKGROUND: High post-treatment platelet reactivity has been reported after coronary stenting after clopidogrel therapy and may be an important factor in the occurrence of SAT.

METHODS: We identified patients with SAT treated at two tertiary care centers over a 1.5-year period. Light transmittance aggregation induced by adenosine diphosphate (ADP) and arachidonic acid, total and activated glycoprotein (GP) IIb/IIIa after stimulation with ADP, and vasodilator-stimulated phosphoprotein phosphorylation levels to measure P2Y12 receptor inhibition were determined (n = 20) and compared with an age-matched group of patients without SAT (n = 100). High post-treatment platelet reactivity was defined as >75th percentile ADP-induced aggregation in the group without SAT.

RESULTS: The SAT patients had higher mean platelet reactivity than those without SAT by all measurements (p < 0.05): 49 ± 4% versus 33 ± 2% for 5 µmol/l ADP-induced aggregation and 65 ± 3% versus 51 ± 2% for 20 µmol/l ADP-induced aggregation (p < 0.001), 69 ± 5% versus 46 ± 9% for P2Y12 reactivity ratio (p = 0.03), and 138 ± 19 mean fluorescence intensity (MFI) versus 42 ± 4 MFI for stimulated GP IIb/IIIa expression (p < 0.001). Of patients with SAT, 60% had high platelet reactivity.

CONCLUSIONS: High post-treatment platelet reactivity and incomplete P2Y12 receptor inhibition are risk factors for SAT. Measures to uniformly determine platelet reactivity after coronary stenting and treatment strategies to improve P2Y12 receptor inhibition in patients with high post-treatment platelet reactivity should be further investigated.

Abbreviations and Acronyms
  ADP = adenosine diphosphate
  GP = glycoprotein
  MFI = mean fluorescence intensity
  PGE1 = prostaglandin E1
  SAT = stent thrombosis
  VASP = vasodilator-stimulated phosphoprotein




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