Premature antiplatelet therapy discontinuation is a risk factor for
stent thrombosis. In Iakovou’s series (1) DES-thrombosis occurred in 5 of
17 patients (29%) who prematurely discontinued dual antiplatelet therapy.
One of them only discontinued clopidogrel and the others stopped both
antiplatelets (aspirin and clopidogrel or ticlopidine). This is
erroneously reported in the editorial of Gershlick (2) which states that
premature discontinuation of clopidogrel is the greatest risk factor for
stent thrombosis. We do not know whether continuation of aspirin alone
would have been adequate to prevent DES-thrombosis. Moreover, in only a
minority of patients in Iakovou’s register (5 out of 29, i.e. 17%)
discontinuation of antiplatelets seemed to play a role in the occurrence
of stent thrombosis.
The tragedy of DES is not the risk of late stent thrombosis but the
fact that these devices have only a limited effect on our patients well-
being. It has been shown in several randomized trials (3) that they do not
lead to a lower mortality and they do not affect the incidence of acute
myocardial infarction. On the other hand, recently presented meta-analyses
(4) and data from registries (5) suggest that DESs might increase the
occurence of acute infarctions and even late mortality.
The question at hand is not for how long and how many antiplatelets
should be continued following DES implant but whether we should continue
to use this kind of coronary stents in our patients.
1. Iakovou I, Mehran R, Dangas G. Thrombosis after implantation of
drug-eluting stents. Hellenic J Cardiol 2006;47(1):31-8.
2. Gershlick AH, Richardson G. Drug eluting stents. BMJ
2006;333(7581):1233-4.
3. Roiron C, Sanchez P, Bouzamondo A, Lechat P, Montalescot G. Drug
eluting stents: an updated meta-analysis of randomised controlled trials.
Heart 2006;92(5):641-9.
4. Nordmann AJ, Briel M, Bucher HC. Mortality in randomized controlled
trials comparing drug-eluting vs. bare metal stents in coronary artery
disease: a meta-analysis. Eur Heart J 2006;27(23):2784-814.
5. Pfisterer M, Brunner-La Rocca HP, Buser PT, Rickenbacher P, Hunziker P,
Mueller C, 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 2006;48(12):2584-
91.
Rapid Response:
Antiplatelets alone won't do the job.
Premature antiplatelet therapy discontinuation is a risk factor for
stent thrombosis. In Iakovou’s series (1) DES-thrombosis occurred in 5 of
17 patients (29%) who prematurely discontinued dual antiplatelet therapy.
One of them only discontinued clopidogrel and the others stopped both
antiplatelets (aspirin and clopidogrel or ticlopidine). This is
erroneously reported in the editorial of Gershlick (2) which states that
premature discontinuation of clopidogrel is the greatest risk factor for
stent thrombosis. We do not know whether continuation of aspirin alone
would have been adequate to prevent DES-thrombosis. Moreover, in only a
minority of patients in Iakovou’s register (5 out of 29, i.e. 17%)
discontinuation of antiplatelets seemed to play a role in the occurrence
of stent thrombosis.
The tragedy of DES is not the risk of late stent thrombosis but the
fact that these devices have only a limited effect on our patients well-
being. It has been shown in several randomized trials (3) that they do not
lead to a lower mortality and they do not affect the incidence of acute
myocardial infarction. On the other hand, recently presented meta-analyses
(4) and data from registries (5) suggest that DESs might increase the
occurence of acute infarctions and even late mortality.
The question at hand is not for how long and how many antiplatelets
should be continued following DES implant but whether we should continue
to use this kind of coronary stents in our patients.
1. Iakovou I, Mehran R, Dangas G. Thrombosis after implantation of
drug-eluting stents. Hellenic J Cardiol 2006;47(1):31-8.
2. Gershlick AH, Richardson G. Drug eluting stents. BMJ
2006;333(7581):1233-4.
3. Roiron C, Sanchez P, Bouzamondo A, Lechat P, Montalescot G. Drug
eluting stents: an updated meta-analysis of randomised controlled trials.
Heart 2006;92(5):641-9.
4. Nordmann AJ, Briel M, Bucher HC. Mortality in randomized controlled
trials comparing drug-eluting vs. bare metal stents in coronary artery
disease: a meta-analysis. Eur Heart J 2006;27(23):2784-814.
5. Pfisterer M, Brunner-La Rocca HP, Buser PT, Rickenbacher P, Hunziker P,
Mueller C, 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 2006;48(12):2584-
91.
Competing interests:
None declared
Competing interests: No competing interests