CORRESPONDENCE: LETTER TO THE EDITOR
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Somjot S. Brar, MD*,
Albert Yuh-Jer Shen, MD,
Vicken Aharonian, MD,
Prakash Mansukhani, MD and
John Kim, MD
* Columbia University Medical Center, Center for Interventional Vascular Therapy, 161 Forth Washington Avenue, 5th Floor, New York, New York 10032 (Email: SBrar{at}cvri.org).
We thank Dr. Kaneda for his interest and comments regarding our recent publication (1). These comments highlight the complexities interrelating diabetes and stent thrombosis.
In patients with diabetes, there is generally more severe and diffuse atherosclerosis, which accounts, in part, for the higher rates of adverse cardiovascular events. In this setting, it can be difficult to discern stent thrombosis from plaque rupture within or adjacent to a stent. On occasion, plaque rupture, strut fracture, or another etiology for stent thrombosis can be identified by fluoroscopy. The use of intravascular ultrasound can provide additional mechanistic insight (2). However, the use of intravascular ultrasound is not uniform among studies noting an association between diabetes and stent thrombosis. Even with a thorough evaluation, misclassification of stent thrombosis remains a concern. Therefore, it is not surprising that a cohort at high risk for coronary events, in particular plaque rupture, will also be identified as at high risk for stent thrombosis. This possible misclassification of stent thrombotic events will create a systematic bias that may inflate the observed association between diabetes and stent thrombosis and is not amenable to correction or adjustment with multiple regression models. Whether after more careful determination of the etiology of stent thrombosis this association remains is unknown. Newer imaging modalities may help in this evaluation (3).
The clinical implication of the possible association of diabetes and stent thrombosis remains unclear. We feel that the risk of stent thrombosis should be tempered against the marked reduction in restenosis observed across multiple studies (4,5). Moreover, our observations support long-term clopidogrel therapy in this high-risk cohort and suggest that the best outcomes may be achieved with the combination of long-term clopidogrel therapy and use of drug-eluting stents, manifested as a reduction in myocardial infarction or death. A large randomized controlled trial with sufficient follow-up will be required to definitively answer these questions.
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1. Brar SS, Kim J, Brar SK, et al. Long-term outcomes by clopidogrel duration and stent type in a diabetic population with de novo coronary artery lesions J Am Coll Cardiol 2008;51:2220-2227.[Abstract/Free Full Text]2. Mintz GS, Weissman NJ. Intravascular ultrasound in the drug-eluting stent era J Am Coll Cardiol 2006;48:421-429.[Abstract/Free Full Text] 3. Kubo T, Imanishi T, Takarada S, et al. Assessment of culprit lesion morphology in acute myocardial infarction: ability of optical coherence tomography compared with intravascular ultrasound and coronary angioscopy J Am Coll Cardiol 2007;50:933-939.[Abstract/Free Full Text] 4. Kirtane AJ, Ellis SG, Dawkins KD, et al. Paclitaxel-eluting coronary stents in patients with diabetes mellitus: pooled analysis from 5 randomized trials J Am Coll Cardiol 2008;51:708-715.[Abstract/Free Full Text] 5. Baumgart D, Klauss V, Baer F, et al. One-year results of the SCORPIUS study: a German multicenter investigation on the effectiveness of sirolimus-eluting stents in diabetic patients J Am Coll Cardiol 2007;50:1627-1634.[Abstract/Free Full Text]
Related Article
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Endothelialization and Late Stent Thrombosis in Diabetics
- Hideaki Kaneda
J. Am. Coll. Cardiol. 2008 52: 2213.
[Full Text]
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