Stent Thrombosis Risk Over Time on the Basis of Clinical Presentation and Platelet Reactivity: Analysis From ADAPT-DES.

Objectives: The aim of this study was to determine the risk period for increased stent thrombosis (ST) after percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) and whether this increased risk is related to high platelet reactivity (HPR).
Background: ST risk after PCI is higher among patients with ACS than those with stable ischemic heart disease. When ST risk is highest in patients with ACS and how that is affected by HPR is unknown.
Methods: Using the ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) registry, ST rates during 2-year follow-up post-PCI with drug-eluting stents were compared among patients presenting with ACS (myocardial infarction [MI] or unstable angina) or stable ischemic heart disease (non-ACS). Landmark analyses were done at 30 days and 1 year post-PCI. Platelet reactivity on aspirin and clopidogrel post-PCI was assessed using VerifyNow assays.
Results: Of 8,582 patients, 2,063 presented with MI, 2,370 with unstable angina, and 4,149 with non-ACS. Incidence rates of HPR were 48.0%, 43.3%, and 39.8%, respectively (p < 0.001). Within the first 30 days post-PCI, patients presenting with MI had increased ST risk compared with patients with non-ACS (hazard ratio [HR]: 4.52; 95% confidence interval [CI]: 2.01 to 10.14; p < 0.001). After 30 days, relative ST risks were progressively lower and no longer significant between groups (31 days to 1 year post-PCI: HR: 1.97; 95% CI: 0.80 to 4.85; >1 year post-PCI: HR: 0.89; 95% CI: 0.27 to 2.92). The elevated ST risk in patients with MI within 30 days was largely confined to those with HPR on clopidogrel (HR: 5.77; 95% CI: 2.13 to 15.63; p < 0.001).
Conclusions: Among patients undergoing PCI, rates of ST during 2-year follow-up were highest in those with MI and lowest in those with non-ACS. Increased ST risk in patients with MI was greatest in the first 30 days post-PCI and was observed predominantly among those with increased HPR on clopidogrel. These findings emphasize the importance of adequate P2Y ₁₂ inhibition after MI, especially within the first 30 days after stent implantation.
Competing Interests: Funding Support And Author Disclosures The ADAPT-DES study was sponsored by the Cardiovascular Research Foundation, with funding provided by Boston Scientific, Abbott Vascular, Medtronic, Cordis, Biosensors, The Medicines Company, Daiichi-Sankyo, Eli Lilly, Volcano, and Accumetrics. Dr. Chau has received an institutional grant from the National Heart, Lung, and Blood Institute to Columbia University Irving Medical Center (T32 HL007854). Dr. Kirtane has received institutional funding to Columbia University and/or the Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, Cardiovascular Systems, CathWorks, Siemens, Philips, and ReCor Medical (in addition to research grants, institutional funding includes fees paid to Columbia University and/or the Cardiovascular Research Foundation for speaking engagements and/or consulting; no speaker or consulting fees were personally received); and has received reimbursement for travel expenses and meals from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, Cardiovascular Systems, CathWorks, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron. Dr. Weisz is an advisory board member for Corindus, Filterlex, and TriSol; and has received institutional grant support from Abbott, Ancora, Corindus, Cardiovascular Systems, Shockwave, Svelte, and V-Wave. Dr. Stuckey is an advisory board member for Boston Scientific; and has received speaker honoraria from Boston Scientific and Eli Lilly/Daiichi-Sankyo. Dr. Rinaldi is an advisory board member for Abbott, Boston Scientific, Cordis, and 4C Medical; teaches courses for Abbott and Edwards Lifesciences; is a consultant to Abbott, Boston, Edwards Lifesciences, and Cordis; and has received research support and grant funding from Boston Scientific. Dr. Neumann has received institutional research grants, consultancy fees, and speaker honoraria from Daiichi-Sankyo, AstraZeneca, Sanofi, Bayer, The Medicines Company, Bristol Myers Squibb, Novartis, Roche, Boston Scientific, Biotronik, Medtronic, Edwards Lifesciences, and Ferrer. Dr. Metzger has received symposium honoraria from Abbott Vascular and Boston Scientific. Dr. Henry is a scientific advisory board member for Abbott Vascular, Boston Scientific, and The Medicines Company; and is a steering committee member for the TRANSLATE study, sponsored by Eli Lilly and Daiichi-Sankyo. Dr. Cox is a consultant to Abbott Vascular, Boston Scientific, and Medtronic. Dr. Duffy is a consultant and speaker for Philips Medical/Volcano. Dr. Mehran has received institutional research grants from Abbott Laboratories, AstraZeneca, Bayer, Beth Israel Deaconess, Bristol Myers Squibb, CERC, Chiesi, Concept Medical, CSL Behring, DSI, Medtronic, Novartis Pharmaceuticals, and OrbusNeich; has received consulting fees from Abbott Laboratories, Boston Scientific, Janssen Scientific Affairs, Medscape/WebMD, Medtelligence (Janssen Scientific Affairs), Roivant Sciences, Sanofi, and Siemens Medical Solutions; has received consulting fees paid to the institution from Abbott Laboratories and Bristol Myers Squibb; is an advisory board member for and has received funding paid to the institution from Spectranetics/Philips/Volcano; holds equity (<1%) in Claret Medical and Elixir Medical; has received data and safety monitoring board membership fees paid to the institution from Watermark Research Partners; is a consultant (no fees) for Idorsia Pharmaceuticals and Regeneron Pharmaceuticals; and is an associate editor for the American College of Cardiology and the American Medical Association; and her spouse is a consultant to Abiomed and The Medicines Company. Dr. Stone has received speaker or other honoraria from Cook, Terumo, Qool Therapeutics, and Orchestra Biomed; is a consultant to Valfix, TherOx, Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions, Miracor, Neovasc, V-Wave, Abiomed, Ancora, MAIA Pharmaceuticals, Vectorious, Reva, Matrizyme, and Cardiomech; holds equity or options in Ancora, Qool Therapeutics, Cagent, Applied Therapeutics, the Biostar family of funds, SpectraWave, Orchestra Biomed, Aria, Cardiac Success, the MedFocus family of funds, and Valfix. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
(Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)