|
| HOME | SUBSCRIPTIONS | CURRENT ISSUE | PAST ISSUES | CARDIOSOURCE | SEARCH | HELP | FEEDBACK |
|
|
|
|||||||||
|
|||||||||||
|
J Am Coll Cardiol, 2005; 45:947-953, doi:10.1016/j.jacc.2004.09.079 © 2005 by the American College of Cardiology Foundation |
Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
Manuscript received August 26, 2004; revised manuscript received September 23, 2004, accepted September 28, 2004.
* Reprint requests and correspondence: Dr. Patrick W. Serruys, Thoraxcenter, Bd-406, Dr. Molewaterplein 40, 3015-GD Rotterdam, Netherlands (Email: p.w.j.c.serruys{at}erasmusmc.nl).
 |
Abstract |
|---|
 Top Abstract MethodsResultsDiscussionReferences |
|---|
BACKGROUND: Current data on ST in drug-eluting stents (DES) have come from randomized trials with strict entry criteria, which limits their generalizability to daily practice.
METHODS: The study population comprised three sequential cohorts of 506 consecutive patients with BMS, 1,017 consecutive patients with SES, and 989 consecutive patients treated with PES.
RESULTS: In the first 30 days after stent implantation, 6 BMS (1.2%, 95% confidence interval [CI] 0.5% to 2.6%; p = 0.9), 10 SES (1.0%, 95% CI 0.5% to 1.8%), and 10 PES (1.0%, 95% CI 0.6% to 1.9%) patients developed angiographically proven ST. Multiple potential risk factors were identified in most patients with ST. Bifurcation stenting in the setting of acute myocardial infarction was an independent risk factor for angiographic ST in the entire population (odds ratio [OR] 12.9, 95% CI 4.7 to 35.8, p < 0.001). In patients with DES who had angiographic ST, 30-day mortality was 15%, whereas another 60% suffered a nonfatal myocardial infarction; no further deaths occurred during six months of follow-up. Including possible cases, 7 BMS (1.4%, 95% CI 0.7% to 2.8%), 15 SES (1.5%, 95% CI 0.9% to 2.4%), and 16 PES (1.6%, 95% CI 1.0% to 2.6%) patients had ST.
CONCLUSIONS: The unrestricted use of SES or PES is associated with ST rates in the range expected for BMS. Stent thrombosis was associated with a high morbidity and mortality. Bifurcation stenting, when performed in patients with acute myocardial infarction, was associated with an increased risk of ST.
| ||||||||||||
|
Methods |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
This present study comprises three sequential cohorts: a control group of the last 506 consecutive patients treated with BMS before April 2002; 1,017 consecutive patients with SES treated between April 2002 and February 2003; and 989 consecutive patients with PES treated between February 2003 and December 2003.
Procedure and antiplatelet management. All interventions were performed according to current standard guidelines, and the final interventional strategy including periprocedural glycoprotein IIb/IIIa and intravascular ultrasound use, was left to the discretion of the operator. Patients were pretreated with aspirin and a loading dose of 300 mg of clopidogrel. After their procedure, all patients were prescribed a lifelong aspirin regimen. Clopidogrel was prescribed for at least one month in the BMS group, for at least three months in the SES group (8), and for at least six months in the PES group.
Follow-up. As part of the national health system, our institution as a tertiary referral center is the only interventional facility within our catchment area. The survival status of our patients at one and six months after discharge was obtained from the Municipal Civil Registries. Details of all repeat interventions (surgical and percutaneous) were collected prospectively during follow-up. Referring physicians and institutions were contacted whenever necessary for additional information. This protocol was approved by the Hospital Ethics Committee, and written, informed consent was obtained from every patient.
Definitions. Stent thrombosis was considered to have occurred when confirmed angiographically: either Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 or 1 or the presence of flow-limiting thrombus (TIMI flow grade 1 or 2) occurring in an acute (within 24 h of stent implantation) or subacute (between 1 and 30 days) time period after stent implantation (9). In addition, a clinical definition of "possible stent thrombosis" was used for patients who within the first 30 days experienced sudden death, who suffered a fatal out-of-hospital cardiac arrest, or who suffered a myocardial infarction (MI) that was not clearly attributable to another coronary lesion and who did not undergo repeat angiography. All deaths and MIs were reviewed independently by two interventional cardiologists (A.O., E.Mc.F) for "possible stent thrombosis."
Statistical analysis. Categorical variables were compared using the Fisher exact test and continuous variables with the Student t test or one-way analysis of variance where appropriate. Univariate and forward stepwise (entry criteria of 0.05 and exit criteria of 0.10) multivariate logistic regression analysis were performed to identify characteristics or variables independently associated with stent thrombosis. From the univariate analysis, the following baseline, clinical, angiographic and procedural variables were entered into the multivariate model: bifurcation stenting, diabetes, smallest stent diameter, multilesion stenting, and acute myocardial infarction (AMI) as the indication. All probability values are two-sided, and statistical significance was set at the 0.05 level. A cumulative event graph consisting of patients with angiographic stent thrombosis was generated plotting the proportion of patients with stent thrombosis (Y-axis) against time (X-axis) stratified by stent type. Incidences of stent thrombosis are reported as a percentage with associated 95% confidence intervals (CIs).
|
Results |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
|
|
|
|
Possible ST. Thirty-day survival data was complete for 98% of patients (Table 4). There were 12 patients who were judged with "possible stent thrombosis," of which 9 died and 3 had nonfatal MIs. Of the nine deaths, four were out-of-hospital sudden deaths, three occurred in hospital with ventricular tachycardia as the initiating preterminal rhythm, and two had ST-segment elevation and died before they could undergo reangiography. Among those with MIs, one patient developed a postprocedural enzyme leak, and another developed ventricular fibrillation requiring multiple cardioversions the day after the procedure. Repeat coronary angiography six months later demonstrated occluded stents in both of these patients; whereas a third underwent coronary angiography 14 days after stent implantation because of an increase in cardiac enzyme levels, which demonstrated an in-stent filling defect which was treated with abciximab, and subsequently underwent repeat percutaneous coronary intervention two weeks later. Including the suspected cases, the combined incidence of angiographic and possible ST was 1.4% (95% CI 0.7% to 2.8%) in the BMS control group, 1.5% (95% CI 0.9% to 2.4%) in the SES group, and 1.6% (95% CI 1.0% to 2.6%) in the PES group. In the combined total of 38 documented and possible ST, there were 12 deaths (32%) and 20 nonfatal MIs (53%) in the first 30 days.
|
|
Discussion |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
1.0%), within the same range as the corresponding BMS population and concordant with previously published results from the BMS era; 2) the inclusion of possible ST increases the overall incidence of ST to 1.5%; 3) angiographically proven ST was associated with a high mortality and morbidity; 4) patients who developed ST often had multiple high-risk features, regardless of stent type; and 5) the association of bifurcation stenting for AMI was a highly significant independent risk factor for ST. The availability of DES as the default stent at our institution has allowed us to analyze this new technology in an unrestricted population (8), a population that would have comprised any BMS population in the pre-DES era. Therefore, this availability allows us to analyze incidences in an "all-comers" population because patients were enrolled irrespective of clinical presentation or outcome. In this population sample, angiographic ST rates in the first 30 days for both DES, i.e., SES and PES, occurred within the range as that reported in the BMS era (1,2,11,12).
The angiographic definition used is the most accurate for diagnosis but may underestimate the true incidence of ST because some patients who have a presumed ST may die before receiving medical attention. Conversely, the use of major adverse cardiac events (i.e., death and MI in addition to the angiographic findings) to define ST overestimates the true incidence because not all patients who die suddenly or suffer a MI do so because of ST (13). This consideration is important in our heterogeneous unrestricted population with multivessel disease, previous MI, and previous revascularization. Furthermore, not all patients who die will undergo autopsy studies to determine the cause of death. To attenuate this overestimation and to provide an accurate figure, we have adjudicated all deaths and noncatheterized, nonfatal MIs within the first 30 days in the three groups and included them with the angiographically proven patients to provide an overall incidence for each group.
The incidences of ST for both groups of DES are within the range reported in the larger randomized clinical trials of DES (3–6) despite longer total stent length, multivessel treatment, and a heterogeneous population (Table 5). This incidence complements information already available from the randomized trials regarding the safety of these new devices.
|
Previous studies have demonstrated that residual dissection (1,11), long stents (1), small final lumen diameter (1), and use of multiple stents (2) are risk factors for the development of ST. In our series, multiple risk factors were identified in most patients who developed ST. Patients with ST had more multiple lesions treated, smaller minimum stent diameters, and longer stent lengths compared with those without ST; however, these factors were not significant on univariate analysis. What did emerge and which has not been previously reported is that patients undergoing bifurcation stenting had a higher incidence of ST compared with those without bifurcation stenting. A recent study on bifurcations reported a 3.5% incidence of ST, which is higher than the overall incidence in this population (14).
Although stent implantation for AMI was not significant on univariate analysis, the interaction of AMI and bifurcation stenting when entered as a covariate for ST on multivariate analysis emerged as a highly significant independent predictor, and bifurcation stenting as a covariate was no longer significant. This result confirms a clinical suspicion in our department regarding the increased risk of ST in patients treated with bifurcation stenting in the setting of AMI.
Mechanical reasons that predispose to ST can be modified by interventional technique. Optimizing stent placement including, if necessary, intravascular ultrasound-guided postdilation, kissing balloon postdilation with bifurcation stenting, and careful inspection for residual dissection after stent implantation, may further reduce the incidence of ST.
Pharmacologic reasons for ST, i.e., inadequate antiplatelet therapy, are patient-specific factors. Recent research literature has focused on "resistance" to either aspirin (15) or to clopidogrel (16). Currently, most laboratories do not routinely test for antiplatelet resistance. In our series, two patients who had not taken their prescribed clopidogrel after the procedure developed ST.
This report covers ST occurring in the first 30 days after stent implantation only, during which all patients received dual antiplatelet therapy. The duration of clopidogrel therapy differed among the three groups; in part, it reflects uncertainty with regards to re-endothelialization after DES implantation. Late ST has been reported to occur with BMS (17) and with DES (18), including a reported fatality (19) after clopidogrel discontinuation. At this stage, the incidence of late ST in the DES era is unknown, and further studies are required to clarify this potential late complication.
Comment on sample size and statistical comparisons.
Because ST occurs at a low incidence (1.0 to 1.5%), a small sample size may underestimate or overestimate the true incidence. In a previously published report from our institution, we reported an angiographic incidence of 0.4% in 508 patients (8). In the present study we extended the population to incorporate the entire period of DES used to date at our institution (n = 2,006) to allow a more accurate analysis of the true incidence of ST in the DES population. Despite having 2,512 patients, the low and small/negligible absolute difference in incidence precludes formal statistical comparisons of ST rates among the three groups because it lacks sufficient statistical power. To achieve adequate power would require sample sizes in the order of >100,000 patients. To date, this study is the largest series of patients reported on in the DES era.
Study limitations. These single-center registry data complement available randomized data, as they reflect the results of unrestricted DES use.
Conclusions.
Despite having a more complex cohort with high-risk inclusion criteria, longer stent lengths, and more complex procedural features, the incidence of ST with DES are in the same range as the BMS population observed in our present study. They also are in agreement with previously reported data by others from the BMS era and with those results reported on in the earlier randomized DES trials. Furthermore, the two groups of DES, i.e., SES and PES, share an incidence of 1.0% to 1.5%. Stent thrombosis is associated with a high morbidity and mortality.
As extensively documented in previous reports with BMS, mechanical reasons were observed to be frequent associations for ST with DES. In this study, bifurcation stenting in the setting of AMI was a highly significant independent predictor for angiographic ST.
|
Acknowledgments |
|---|
|
Footnotes |
|---|
|
References |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  L. T. Newsome, M. A. Kutcher, and R. L. Royster Coronary Artery Stents: Part I. Evolution of Percutaneous Coronary Intervention Anesth. Analg., August 1, 2008; 107(2): 552 - 569. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. T. Newsome, R. S. Weller, J. C. Gerancher, M. A. Kutcher, and R. L. Royster Coronary Artery Stents: II. Perioperative Considerations and Management Anesth. Analg., August 1, 2008; 107(2): 570 - 590. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. J. Malenka, A. V. Kaplan, F. L. Lucas, S. M. Sharp, and J. S. Skinner Outcomes Following Coronary Stenting in the Era of Bare-Metal vs the Era of Drug-Eluting Stents JAMA, June 25, 2008; 299(24): 2868 - 2876. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. Chechi, S. Vecchio, G. Vittori, G. Giuliani, A. Lilli, G. Spaziani, L. Consoli, G. Baldereschi, G. G.L. Biondi-Zoccai, I. Sheiban, et al. ST-segment elevation myocardial infarction due to early and late stent thrombosis a new group of high-risk patients. J. Am. Coll. Cardiol., June 24, 2008; 51(25): 2396 - 2402. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Latib and A. Colombo Bifurcation Disease: What Do We Know, What Should We Do? J. Am. Coll. Cardiol. Intv., June 1, 2008; 1(3): 218 - 226. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Li, R. Jabara, L. Pendyala, Y. Otsuka, T. Shinke, D. Hou, K. Robinson, and N. Chronos Abnormal Vasomotor Function of Porcine Coronary Arteries Distal to Sirolimus-Eluting Stents J. Am. Coll. Cardiol. Intv., June 1, 2008; 1(3): 279 - 285. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Garg, D. J. Cohen, T. Gaziano, and L. Mauri Balancing the Risks of Restenosis and Stent Thrombosis in Bare-Metal Versus Drug-Eluting Stents: Results of a Decision Analytic Model J. Am. Coll. Cardiol., May 13, 2008; 51(19): 1844 - 1853. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. L. Hannan, M. Racz, D. R. Holmes, G. Walford, S. Sharma, S. Katz, R. H. Jones, and S. B. King III Comparison of Coronary Artery Stenting Outcomes in the Eras Before and After the Introduction of Drug-Eluting Stents Circulation, April 22, 2008; 117(16): 2071 - 2078. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Bonello, L. Camoin-Jau, S. Arques, C. Boyer, D. Panagides, O. Wittenberg, M.-C. Simeoni, P. Barragan, F. Dignat-George, and F. Paganelli Adjusted Clopidogrel Loading Doses According to Vasodilator-Stimulated Phosphoprotein Phosphorylation Index Decrease Rate of Major Adverse Cardiovascular Events in Patients With Clopidogrel Resistance: A Multicenter Randomized Prospective Study J. Am. Coll. Cardiol., April 8, 2008; 51(14): 1404 - 1411. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. J. Price, S. Endemann, R. R. Gollapudi, R. Valencia, C. T. Stinis, J. P. Levisay, A. Ernst, N. S. Sawhney, R. A. Schatz, and P. S. Teirstein Prognostic significance of post-clopidogrel platelet reactivity assessed by a point-of-care assay on thrombotic events after drug-eluting stent implantation Eur. Heart J., April 2, 2008; 29(8): 992 - 1000. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. L. Hannan, M. Racz, G. Walford, D. R. Holmes, R. H. Jones, S. Sharma, S. Katz, and S. B. King III Drug-Eluting Versus Bare-Metal Stents in the Treatment of Patients With ST-Segment Elevation Myocardial Infarction J. Am. Coll. Cardiol. Intv., April 1, 2008; 1(2): 129 - 135. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Godet, Y. Le Manach, F. Lesache, S. Perbet, and P. Coriat Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: is it always a problem? Br. J. Anaesth., April 1, 2008; 100(4): 472 - 477. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. M. de la Torre-Hernandez, F. Alfonso, F. Hernandez, J. Elizaga, M. Sanmartin, E. Pinar, I. Lozano, J. M. Vazquez, J. Botas, A. Perez de Prado, et al. Drug-eluting stent thrombosis: results from the multicenter Spanish registry ESTROFA (Estudio ESpanol sobre TROmbosis de stents FArmacoactivos). J. Am. Coll. Cardiol., March 11, 2008; 51(10): 986 - 990. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. M. Ruiz-Nodar, F. Marin, J. A. Hurtado, J. Valencia, E. Pinar, J. Pineda, J. R. Gimeno, F. Sogorb, M. Valdes, and G. Y.H. Lip Anticoagulant and Antiplatelet Therapy Use in 426 Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention and Stent Implantation: Implications for Bleeding Risk and Prognosis J. Am. Coll. Cardiol., February 26, 2008; 51(8): 818 - 825. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. L. Hannan, C. Wu, G. Walford, A. T. Culliford, J. P. Gold, C. R. Smith, R. S.D. Higgins, R. E. Carlson, and R. H. Jones Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease N. Engl. J. Med., January 24, 2008; 358(4): 331 - 341. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Windecker and B. Meier Late Coronary Stent Thrombosis Circulation, October 23, 2007; 116(17): 1952 - 1965. [Full Text] [PDF]
|
|
|
|
|
|
J. Daemen and P. W. Serruys Drug-Eluting Stent Update 2007: Part II: Unsettled Issues Circulation, August 21, 2007; 116(8): 961 - 968. [Full Text] [PDF]
|
|
|
|
|
|
G. Sianos, M. I. Papafaklis, J. Daemen, S. Vaina, C. A. van Mieghem, R. T. van Domburg, L. K. Michalis, and P. W. Serruys Angiographic Stent Thrombosis After Routine Use of Drug-Eluting Stents in ST-Segment Elevation Myocardial Infarction: The Importance of Thrombus Burden J. Am. Coll. Cardiol., August 14, 2007; 50(7): 573 - 583. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Airoldi, A. Colombo, N. Morici, A. Latib, J. Cosgrave, L. Buellesfeld, E. Bonizzoni, M. Carlino, U. Gerckens, C. Godino, et al. Incidence and Predictors of Drug-Eluting Stent Thrombosis During and After Discontinuation of Thienopyridine Treatment Circulation, August 14, 2007; 116(7): 745 - 754. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. R Bennett Vascular pathology as a result of drug-eluting stents Heart, August 1, 2007; 93(8): 895 - 896. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Valgimigli, G. Campo, C. Arcozzi, P. Malagutti, R. Carletti, F. Ferrari, D. Barbieri, G. Parrinello, G. Percoco, and R. Ferrari Two-Year Clinical Follow-Up After Sirolimus-Eluting Versus Bare-Metal Stent Implantation Assisted by Systematic Glycoprotein IIb/IIIa Inhibitor Infusion in Patients With Myocardial Infarction: Results From the STRATEGY Study J. Am. Coll. Cardiol., July 10, 2007; 50(2): 138 - 145. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Jaffe and B. H. Strauss Late and Very Late Thrombosis of Drug-Eluting Stents: Evolving Concepts and Perspectives J. Am. Coll. Cardiol., July 10, 2007; 50(2): 119 - 127. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. R. Holmes Jr, D. J. Kereiakes, W. K. Laskey, A. Colombo, S. G. Ellis, T. D. Henry, J. J. Popma, P. W.J.C. Serruys, T. Kimura, D. O. Williams, et al. Thrombosis and Drug-Eluting Stents: An Objective Appraisal J. Am. Coll. Cardiol., July 10, 2007; 50(2): 109 - 118. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Authors/Task Force Members, J.-P. Bassand, C. W. Hamm, D. Ardissino, E. Boersma, A. Budaj, F. Fernandez-Aviles, K. A.A. Fox, D. Hasdai, E. M. Ohman, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology Eur. Heart J., July 1, 2007; 28(13): 1598 - 1660. [Full Text] [PDF]
|
|
|
|
|
|
P. Buonamici, R. Marcucci, A. Migliorini, G. F. Gensini, A. Santini, R. Paniccia, G. Moschi, A. M. Gori, R. Abbate, and D. Antoniucci Impact of Platelet Reactivity After Clopidogrel Administration on Drug-Eluting Stent Thrombosis J. Am. Coll. Cardiol., June 19, 2007; 49(24): 2312 - 2317. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. W. Stone, S. G. Ellis, A. Colombo, K. D. Dawkins, E. Grube, D. E. Cutlip, M. Friedman, D. S. Baim, and J. Koglin Offsetting Impact of Thrombosis and Restenosis on the Occurrence of Death and Myocardial Infarction After Paclitaxel-Eluting and Bare Metal Stent Implantation Circulation, June 5, 2007; 115(22): 2842 - 2847. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. M. Howard-Alpe, J. de Bono, L. Hudsmith, W. P. Orr, P. Foex, and J. W. Sear Coronary artery stents and non-cardiac surgery Br. J. Anaesth., May 1, 2007; 98(5): 560 - 574. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. E. Cutlip, S. Windecker, R. Mehran, A. Boam, D. J. Cohen, G.-A. van Es, P. Gabriel Steg, M.-a. Morel, L. Mauri, P. Vranckx, et al. Clinical End Points in Coronary Stent Trials: A Case for Standardized Definitions Circulation, May 1, 2007; 115(17): 2344 - 2351. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. W. Stone, J. W. Moses, S. G. Ellis, J. Schofer, K. D. Dawkins, M.-C. Morice, A. Colombo, E. Schampaert, E. Grube, A. J. Kirtane, et al. Safety and Efficacy of Sirolimus- and Paclitaxel-Eluting Coronary Stents N. Engl. J. Med., March 8, 2007; 356(10): 998 - 1008. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. P. Karjalainen, P. Porela, A. Ylitalo, S. Vikman, K. Nyman, M.-A. Vaittinen, T. J. Airaksinen, M. Niemela, T. Vahlberg, and K.E. J. Airaksinen Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting Eur. Heart J., March 2, 2007; 28(6): 726 - 732. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. F. Luscher, J. Steffel, F. R. Eberli, M. Joner, G. Nakazawa, F. C. Tanner, and R. Virmani Drug-Eluting Stent and Coronary Thrombosis: Biological Mechanisms and Clinical Implications Circulation, February 27, 2007; 115(8): 1051 - 1058. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. L. Eisenstein, K. J. Anstrom, D. F. Kong, L. K. Shaw, R. H. Tuttle, D. B. Mark, J. M. Kramer, R. A. Harrington, D. B. Matchar, D. E. Kandzari, et al. Clopidogrel Use and Long-term Clinical Outcomes After Drug-Eluting Stent Implantation JAMA, January 10, 2007; 297(2): 159 - 168. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Pfisterer, H. P. Brunner-La Rocca, P. T. Buser, P. Rickenbacher, P. Hunziker, C. Mueller, R. Jeger, F. Bader, S. Osswald, C. Kaiser, et al. Late Clinical Events After Clopidogrel Discontinuation May Limit the Benefit of Drug-Eluting Stents: An Observational Study of Drug-Eluting Versus Bare-Metal Stents J. Am. Coll. Cardiol., December 19, 2006; 48(12): 2584 - 2591. [Abstract] [Full Text] |
