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August 2013


Cardiogenic shock is strongest predictor of stent thrombosis


A real-world, all-comers, registry study—published in EuroIntervention and presented at EuroPCR (21–24 May, Paris, France)— indicates that the incidence of stent thrombosis is 1.9% and that cardiogenic shock (often excluded in clinical trials) is the strongest independent predictor for the complication


J


avaid Iqbal (Department of Cardio- vascular Science, University of Shef- field, Sheffield, UK) and others wrote that there was a need for contemporary registries to examine the incidence and risk of stent thrombosis because: “The clinical trials tend to present stent throm- bosis rates for a particular type of stent used in a selected patient cohort, whereas the registry data can evaluate the stent


PCI during the study period (2007–2010), 109 (1.9%) had stent thrombosis (70 definite; 39 probable). According to Iqbal et al, this figure is similar to the incidence of stent thrombosis in other contemporary registries. They also commented: “Eighty per cent of definite stent thrombosis presented as acute myocardial infarction and 20% as unstable angina. Six per cent of cases of probable stent thrombosis pre-


Cardiogenic shock was found to be an independent predictor of both definite/probable stent thrombosis and definite stent thrombosis


thrombosis in a real-life experience in a certain geographical area.” Therefore, the authors conducted a retrospective analysis of prospectively collected data of patients undergoing percutaneous coronary inter- vention (PCI) to examine the incidence of stent thrombosis and its risk factors in a real-world, all-comers setting. Of the 5,833 patients who underwent


sented at deaths, 27% as acute myocardial infarction, and 13% as unstable angina.” In a multivariate analysis, cardiogenic shock was found to be an independent predictor of both definite/probable stent thrombosis and definite stent thrombosis alone. Iqbal et al noted: “This has not been previously reported because these very high-risk patients are commonly


excluded from trials and are under- represented even in registries.” They added that the presence of cardiogenic shock could have “important implications for the choice of antiplatelet therapy and revascularisation strategy”, explaining that intravenous antiplatelet therapies may have a role in patients with cardio- genic shock to overcome problems with other therapies. According to the authors, in these patients, the bioavailability of thienopyridine-type antiplatelets may be reduced in cardiogenic shock and the non-thienopyridine oral P2Y12 ticagrelor may also have a delayed onset of action in ST-elevation myocardial infarction (STEMI) patients with cardiogenic shock. Other independent predictors of defi- nite/probable stent thrombosis included lack of dual antiplatelet therapy, diabetes, stent length, stent diameter, type of stent, and three-vessel PCI. Also, Iqbal et al found that cardiogenic shock, stent size, STEMI, diabetes, and three-vessel PCI were associated with early stent thrombo- sis while lack of dual antiplatelet therapy was associated with late stent throm- bosis. Stent length, STEMI, and use of


Research


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Javaid Iqbal


first-generation drug-eluting stents were associated with delayed stent thrombo- sis. They commented: “It is generally advocated that STEMI patients present- ing with cardiogenic shock should have complete (as opposed to culprit-only) revascularisation. However, our results highlighting a very high incidence of stent thrombosis in this cohort provide a note of caution.”


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