European Heart Journal Advance Access originally published online on September 23, 2005
European Heart Journal 2005 26(21):2345-2346; doi:10.1093/eurheartj/ehi546
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The management and prevention of thrombotic stent occlusion: reply
Swiss Cardiovascular Center Bern
Freiburgstrasse
Bern
Switzerland
Swiss Cardiovascular Center Bern
Freiburgstrasse
Bern
Switzerland
Swiss Cardiovascular Center Bern
Freiburgstrasse
Bern
Switzerland
Tel: +41 31 6324497
Fax: +41 31 6324770
E-mail address:
stephan.windecker{at}insel.ch
Dual antiplatelet therapy with aspirin and thienopyridines has been shown superior to treatment with oral anticoagulation and aspirin alone in the prevention of major adverse cardiac events following coronary stent implantation.1 The therapeutic benefit of ticlopidine was somewhat limited by rare but potentially serious adverse effects such as neutropenia and thrombocytopenia. The advent of clopidogrel was associated with a superior haematological safety profile but comparable efficacy in three randomized trials and has largely replaced the use of ticlopidine.2–4
Notwithstanding, the comparative studies had some limitations: (1) the trials were underpowered to detect small but potentially important differences in the incidence of stent thrombosis; (2) the studies differed with respect to the loading dose regimen; and (3) the follow-up period was limited to 30 days. In light of these limitations, the report of Dr Wolak and colleagues of a higher incidence of stent thrombosis with clopidogrel (2.8%) than ticlopidine (0.7%) in an all-comer population of 1519 consecutive patients undergoing bare metal stent implantation is of interest. Their observation is echoed by the extended follow-up data of the randomized trial reported by Mueller et al.5 and our own experience. Thus, we have previously investigated the incidence of stent thrombosis following bare metal stent implantation in 4500 consecutive patients.6 While the overall rate of stent thrombosis was 0.8%, thrombotic stent occlusion occurred in 1.9% of patients with clopidogrel and in 0.6% of patients with ticlopidine treatment (P<0.05). The mechanism for the observed difference in efficacy between ticlopidine and clopidogrel remains unclear but has been related to differences in drug–drug interaction as well as dose and length of treatment with the respective thienopyridine. Stent thrombosis has gained even more importance in the era of drug eluting stents and future studies with long-term follow-up will have to determine the optimal antiplatelet therapy.
References
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[Abstract/Free Full Text] - Bertrand ME, Rupprecht HJ, Urban P, Gershlick AH, Investigators FT. Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting: the clopidogrel aspirin stent international cooperative study (CLASSICS). Circulation 2000;102:624–629.
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