Should antiplatelet therapy be interrupted in drug eluting stent recipients throughout the periendoscopic period？ A very late stent thrombosis case re-port and review of the literature

在在有 drug-eluting stents (DES ) 的病人的 antiplatelet 药的停止以后的 In-stent 血栓是在诊所的一个重要问题，特别地在 perioperative 时期。我们与高血压，冠的动脉疾病和长期的衰退胃炎的病历报导一个 87 岁的人的一个案例。sirolimus-eluting stent 的很迟了的血栓发生了在培植，在 clopidogrel 的中止以后的七个月，和在一个选任的内视镜的胃肠的过程的准备的阿司匹林 13 天的打断以后的 1207 天与尖锐心肌的梗塞介绍了。病人与 thrombectomy 并且成功地被对待有二 sirolimus-eluting stents 的重迭的 revascularized。在 catheterization 实验室管理的药包括了低分子的重量肝磷脂和硝化甘油。流动在心肌的梗塞规模被定义为根据 thrombolysis 的等级 2。在揭示的过程以后的心电图坚持，但是减少，处于在前面偏一边的领先的圣片断举起。病人无止境地在阿司匹林和 clopidogrel 上恢复了并且被解除。在二个年后续时期期间没有心脏的事件。这个盒子加重维持血栓的平衡并且与低流血风险在病人之中在 periendoscopic 过程期间在为阿司匹林治疗的继续的非心脏的过程和可能的需要的 perioperation 期间流血的重要性收到了 DES。

What is the Optimal Duration of Dual Antiplatelet Therapy After Stenting?

The optimal duration of dual antiplatelet therapy(DAPT)of aspirin and a P2Y12 receptor blocker after stenting is still being debated.The current recommendations for DAPT duration are signifi cantly focused on reducing stent thrombosis;a less frequent event with later than earlier generation drug eluting stents(DES).A persistent occurrence of late and very late stent thrombosis with first generation DES supported extended use of DAPT beyond one year.However,recent studies have demonstrated that extended duration DAPT is associated with increased bleeding;an independent predictor for poor outcomes,including long-term mortality.Second-generation DES are associated with less late and very late stent thrombosis.Some recent studies have supported a shorter duration of DAPT for second generation DES.However,these studies were inadequately powered to assess signifi cant differences in stent thrombosis.Furthermore,extended duration DAPT has been associated with a reduced risk of thrombotic events in non-culprit vessels in addition to stent thrombosis in patients with acute coronary syndromes(ACS).The higher risk of bleeding associated with extended DAPT therapy provides a strong rationale for personalized DAPT based on patient risk factors(e.g.ACS vs.non-ACS),type of stents,and cost-benefit analyses.

Shortened dual antiplatelet therapy in contemporary percutaneous coronary intervention era

Percutaneous coronary intervention with stenting is followed by a duration of dual antiplatelet therapy(DAPT)to reduce stent thrombosis and avoid target lesion failure.The period of DAPT recommended in international guidelines following drug-eluting stent implantation is 12 mo for most patients with acute coronary syndrome,and 6 mo for patients with chronic coronary syndrome or high bleeding risk.The new generation of drug-eluting stents have metallic platforms with thinner struts,associated with significantly less stent thrombosis.Shortened DAPT has been investigated with these stents,with evidence from randomised clinical trials for some individual stents showing non-inferior safety and efficacy outcomes.This has to be balanced by the effect of DAPT on secondary prevention of systemic cardiovascular disease especially in high-risk populations.This review will outline the current evidence for individual stents with regards to DAPT duration for both acute coronary syndrome and chronic coronary syndrome and discuss further directions for research and personalised medicine in this contemporary percutaneous coronary intervention era.

Antiplatelet therapy resistance induced subacute coronary stent thrombosis in a patient with acute myocardial infarction

Stent implantation has greatly decreased the frequency of acute closure and restenosis after percutaneous coronary inter-vention (PCI) .But stent thrombosis continues to be observed in approximately 1% to 2% of unselected stent procedures and remains a devastating complication.Herein we present a case of subacute coronary stent thrombosis in a patient with anterior AMI treated with double antiplatelet drugs and low molecular weight heparin.

Shorter- versus Longer-duration Dual Antiplatelet Therapy in Patients with Diabetes Mellitus Undergoing Drug-eluting Stents Implantation： A Meta-analysis of Randomized Controlled Trials

Background： Patients with diabetes mellitus （DM） have a higher risk of thromboembolic events： however, the optimal duration of dual antiplatelet therapy （DAPT） remains unclear. The goal of this study was to assess the efficacy and safety of various DAPT durations in patients with DM undergoing drug-eluting stent implantation. Methods： We conducted a literature search for randomized controlled trials （RCTs）. We searched databases including EMBASE, PubMed, Cochrane Library, and Scopus up to June 2016. Investigators extracted data independently, including outcomes, characteristics, and study quality. A random-effect model was used to pool odds ratios （ORs） with 95% confidence intervals （C/s） of the clinical outcomes. Results： Six RCTs totaling 6040 patients with DM were included in the study. Shorter-duration DAPT resulted in an increased rate of stent thrombosis （ST） （OR, 1.83, 95% CI： 1.03-3.26, P = 0.04）, but did not increase the risk of myocardial inihrction （OR. 1.33, 95% CI： 0.71 2.47, P=0.37）, stroke （OR, 0.96, 95% CI： 0.52-1.77, P 0.90）, target vessel revascularization （OR, 1.19, 95% CI： 0.46-3.07, P = 0.71 ）, all-cause death （OR： 0.72, 95% CI： 0.48-1.09, P = 0.12）, or cardiac death （OR, 0.82, 95% CI： 0.49-1.36, P= 0.44） significantly. Shorter-duration DAPT was associated with a decreased risk of major bleeding （OR. 0.60, 95% CI： 0.38-0.94, P = 0.02）. Conclusion： In patients with DM, longer-duration DAPT had a lower risk of ST, but was associated with an increased bleeding risk.

Clinical Impact of Dual Antiplatelet Therapy Use in Patients Following Everolimus-eluting Stent Implantation： Insights from the SEEDS Study

Background:Studies have suggested that use of prolonged dual antiplatelet therapy (DAPT) following new generation drug-eluting stent implantation may increase costs and potential bleeding events.This study aimed to investigate the association of DAPT status with clinical safety in patients undergoing everolimus-eluting stent (EES) implantation in the SEEDS study (A Registry to Evaluate Safety and Effectiveness of Everolimus Drug-eluting Stent for Coronary Revascularization) at 2-year follow-up.Methods:The SEEDS study is a prospective,multicenter study,where patients (n =1900) with small vessel,long lesion,or multi-vessel diseases underwent EES implantation.Detailed DAPT status was collected at baseline,6-month,1-and 2-year.DAPT interruption was defined as any interruption of aspirin and/or clopidogrel more than 14 days.The net adverse clinical events (NACE,a composite endpoint of all-cause death,all myocardial infarction (MI),stroke,definite/probable stent thrombosis (ST),and major bleeding (Bleeding Academic Research Consortium Ⅱ-Ⅴ)) were investigated according to the DAPT status at 2-year follow-up.Results:DAPT was used in 97.8％ of patients at 6 months,69.5％ at 12 months and 35.4％ at 2 years.It was observed that the incidence of NACE was low (8.1％) at 2 years follow-up,especially its components of all-cause death (0.9％),stroke (1.1％),and definite/probable ST (0.7％).DAPT was not an independent predictor of composite endpoint of all-cause death/MI/stroke (hazard ratio [HR]:0.693,95％confidence interval [CI]:0.096-4.980,P =0.715) and NACE (HR:1.041,95％ CI:0.145-7.454,P =0.968).Of 73 patients who had DAPT interruption,no patient had ST at 12-month,and only 1 patient experienced ST between 1-and 2-year (1.4％).There was a high frequency of major bleeding events (53/65,82.5％) occurred in patients receiving DAPT treatment.Conclusions:Prolonged DAPT use was not associated with improved clinical safety.The study emphasized that duration of DAPT needs to be shortened in Chinese patients following EES implantation (ClinicalTrials.gov identifier:NCT 01 157455).

支架内血栓形成病例的临床特点分析

目的:分析支架内血栓形成病例的临床特点并探讨其原因。方法:收集自2007-04至2008-06的所有支架内血栓的患者,共12例。其中男性10例,女性2例。1例置入金属裸支架,其余11例均为药物涂层支架。分析入选病例的临床特点,冠状动脉病变特征。结果:12例患者中,亚急性血栓5例;晚期血栓4例;极晚期血栓3例。分析病变特点及血栓形成原因显示:在早期血栓形成的5例中4例为原发性支架贴壁不良、支架膨胀不良、未完全覆盖病变;1例为糖尿病、长病变、完全闭塞病变。在晚期和极晚期血栓形成的7例病例中3例因为停用了波立维;2例有支架内严重再狭窄;1例为正性重构、获得性贴壁不良;1例为糖尿病、小血管病变,且支架中段扩张不充分不除外贴壁不良的因素。结论:支架内血栓是金属裸支架和药物涂层支架置入术后很少发生但非常严重的并发症。急性的支架内血栓可能与贴壁不良有关。晚期支架内血栓在病因学上是多因素的,主要与双联抗血小板药物治疗依从性相关。

1204例冠状动脉支架血栓患者的抗血小板治疗情况和预后分析

目的:分析冠状动脉(冠脉)造影证实的支架血栓患者的临床特点、抗血小板治疗和预后。方法:纳入北京安贞医院2008-01-01至2016-12-31期间冠脉造影证实的支架血栓患者1 204例,比较急性支架血栓组(<24小时,n=106)、亚急性支架血栓组(24小时～30天,n=206)、晚发支架血栓组(> 30天～1年,n=268)、极晚发支架血栓组(> 1年,n=624)患者的临床特点、抗血小板治疗情况和预后。结果:急性支架血栓组的左前降支发生支架血栓的比例(51.9%)最高。而极晚发支架血栓组中,左心室射血分数<50%(28.2%)及糖尿病患者的比例(34.1%)较高。在确诊支架血栓时,急性支架血栓组均在应用双联抗血小板治疗,96.5%亚急性支架血栓和94.5%晚发支架血栓患者正在使用双联或三联抗血小板治疗;95.2%的极晚发支架血栓患者服用双联抗血小板治疗或单用抗血小板药物。随访期间,四组患者的死亡率分别高达23.6%、26.7%、26.3%和18.9%。结论:绝大多数冠脉支架血栓患者都在接受规范的抗血小板药物治疗,发生支架血栓患者的预后较差。

冠状动脉介入术后双联抗血小板治疗的最佳疗程

冠状动脉介入治疗后进行双联抗血小板治疗已经成为临床治疗的常规,指南推荐至少使用12个月,然而,近年来越来越多的临床试验表明6个月和24个月的疗程对临床后果无明显影响,现通过复习文献对双联抗血小板治疗的最佳疗程做一介绍,并提出如何确定最佳的治疗疗程。

国产钴铬合金平台药物洗脱支架植入术后支架内血栓形成的临床分析

目的:分析国产第二代钴铬合金平台药物洗脱支架(drug-eluting stent,DES)植入术后支架内血栓(stent thrombosis,ST)的发生情况和临床预后,从而为国产第二代DES的推广应用提供临床证据。方法:该研究分析了大型前瞻性、国际多中心注册研究——FOCUS研究中5 084例植入Firebird 2钴铬合金平台DES患者的3年期ST累积发生率,以及ST发生患者的临床特征、双联抗血小板治疗(dual antiplatelet therapy,DAPT)使用情况、ST发生后的处理及预后等。结果:5 084例入选患者中,ST的3年累积发生率为0.67%(35例),包括急性ST 8例,亚急性ST 11例,晚期ST 8例及迟发晚期ST 8例。其中28例再行介入治疗或溶栓治疗后血管再通,其余7例死亡,病死率为20.6%。35例ST患者中,除3例早期停服DAPT、1例仅服用氯吡格雷外,其他患者均接受DAPT治疗至少12个月。结论:FOCUS研究3年随访结果显示国产第二代Firebird 2钴铬合金平台DES植入术后ST的发生率低于1%,为该支架的临床应用提供了依据。

冠状动脉支架置入术后抗血小板治疗和出血风险的综合考量

冠状动脉支架置入术后强化抗血小板治疗可预防支架内血栓形成，置入药物洗脱支架的患者，至少双联抗血小板治疗12个月。但长期的双联抗血小板治疗给患者带来获益的同时也增加了出血风险，因此应根据支架内血栓形成危险分层和出血风险进行综合考量，采取个体化的治疗策略，并加强对患者药学监护、用药宣教和随访管理。在治疗过程中及时发现不良事件及潜在问题，并权衡利弊后处理，保障患者长期抗血小板治疗的安全有效。

氯吡格雷减量与迟发支架内血栓形成

我们报告2例急性心肌梗死患者置入雷帕霉素涂层支架和紫杉醇涂层支架后发生迟发支架内血栓形成的病例。两例患者均为PCI术后服用氯吡格雷(波立维)75mg/日,10～12个月后改为氯吡格雷(泰嘉)50mg/日,服用2个月(即PCI术后12～14个月)出现支架内血栓形成。我们认为:不能对所有的患者都统一予以双重抗血小板药物治疗3～12个月,对于一些高危患者和高危病变,应当适当延长氯比格雷的服用时间,以减少迟发支架内血栓形成的发生率。PCI术后氯比格雷的使用剂量应为75mg/日,而不是50mg/日。

药物洗脱支架血栓形成的机制及防治进展

支架内血栓(ST)形成是经皮冠状动脉介入术治疗后少见的,但却是严重的甚至危及生命的并发症。与金属裸支架相比,药物洗脱支架已使再狭窄的发生率降低,但却使术后ST形成的发生率升高。支架内皮化不全或不内皮化是导致血栓形成的主要原因之一,如何提高支架的内皮化是临床研究的热点。研制新型抗血小板药物、提高支架置入水平,研发新型支架、基因治疗、重视冠心病的二级预防等是预防ST形成的有效措施。