on June 12, 2006
Circulation. 2006
Published online before print June 12, 2006, doi: 10.1161/CIRCULATIONAHA.106.618066
Published online before print June 12, 2006, doi: 10.1161/CIRCULATIONAHA.106.618066
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Submitted on February 1, 2006
From the Mid America Heart Institute and the University of Missouri at Kansas City (J.A.S., R.K., C.V., C.D., P.G.J.); the University of Colorado Hospital/Denver VA Medical Center (J.S.R.), Denver, Colo; the University of Colorado Health Sciences Center (J.C.M.), Denver; the Henry Ford Health System (S.K.), Detroit, Mich; Duke University (E.D.P.), Durham, NC; Barnes-Jewish Hospital and Washington University School of Medicine (R.G.B.), St. Louis, Mo; Yale University (H.M.K.), New Haven, Conn; and Beth Israel-Deaconess Medical Center (D.J.C.), Boston, Mass. * To whom correspondence should be addressed. E-mail: spertusj{at}umkc.edu.
Background--Although drug-eluting stents (DES) significantly reduce restenosis, they require 3 to 6 months of thienopyridine therapy to prevent stent thrombosis. The rate and consequences of prematurely discontinuing thienopyridine therapy after DES placement for acute myocardial infarction (MI) are unknown. Methods and Results--We used prospectively collected data from a 19-center study of MI patients to examine the prevalence and predictors of thienopyridine discontinuation 30 days after DES treatment. We then compared the mortality and cardiac hospitalization rates for the next 11 months between those who stopped and those who continued thienopyridine therapy. Among 500 DES-treated MI patients who were discharged on thienopyridine therapy, 68 (13.6%) stopped therapy within 30 days. Those who stopped were older, less likely to have completed high school or be married, more likely to avoid health care because of cost, and more likely to have had preexisting cardiovascular disease or anemia at presentation. They were also less likely to have received discharge instructions about their medications or a cardiac rehabilitation referral. Patients who stopped thienopyridine therapy by 30 days were more likely to die during the next 11 months (7.5% versus 0.7%, P<0.0001; adjusted hazard ratio=9.0; 95% confidence interval=1.3 to 60.6) and to be rehospitalized (23% versus 14%, P=0.08; adjusted hazard ratio=1.5; 95% confidence interval=0.78 to 3.0). Conclusions--Almost 1 in 7 MI patients who received a DES were no longer taking thienopyridines by 30 days. Prematurely stopping thienopyridine therapy was strongly associated with subsequent mortality. Strategies to improve the use of thienopyridines are needed to optimize the outcomes of MI patients treated with DES.
Revised on April 11, 2006
Accepted on April 20, 2006
Prevalence, Predictors, and Outcomes of Premature Discontinuation of Thienopyridine Therapy After Drug-Eluting Stent Placement. Results From the PREMIER Registry
John A. Spertus MD, MPH*,
Key words: angioplasty • anticoagulants • mortality • revascularization • stents
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J. V. Tu, J. Bowen, M. Chiu, D. T. Ko, P. C. Austin, Y. He, R. Hopkins, J.-E. Tarride, G. Blackhouse, C. Lazzam, et al. Effectiveness and Safety of Drug-Eluting Stents in Ontario N. Engl. J. Med., October 4, 2007; 357(14): 1393 - 1402. [Abstract] [Full Text] [PDF]
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A. Colombo and A. Chieffo Drug-Eluting Stent Update 2007: Part III: Technique and Unapproved/Unsettled Indications (Left Main, Bifurcations, Chronic Total Occlusions, Small Vessels and Long Lesions, Saphenous Vein Grafts, Acute Myocardial Infarctions, and Multivessel Disease) Circulation, September 18, 2007; 116(12): 1424 - 1432. [Full Text] [PDF]
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A. E. Rodriguez, A. O. Maree, J. Mieres, D. Berrocal, L. Grinfeld, C. Fernandez-Pereira, V. Curotto, A. Rodriguez-Granillo, W. O'Neill, and I. F. Palacios Late loss of early benefit from drug-eluting stents when compared with bare-metal stents and coronary artery bypass surgery: 3 years follow-up of the ERACI III registry Eur. Heart J., September 1, 2007; 28(17): 2118 - 2125. [Abstract] [Full Text] [PDF]
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J. Daemen and P. W. Serruys Drug-Eluting Stent Update 2007: Part II: Unsettled Issues Circulation, August 21, 2007; 116(8): 961 - 968. [Full Text] [PDF]
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J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]
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A. A. Bavry and D. L. Bhatt Drug-Eluting Stents: Dual Antiplatelet Therapy for Every Survivor? Circulation, August 14, 2007; 116(7): 696 - 699. [Full Text] [PDF]
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F. Airoldi, A. Colombo, N. Morici, A. Latib, J. Cosgrave, L. Buellesfeld, E. Bonizzoni, M. Carlino, U. Gerckens, C. Godino, et al. Incidence and Predictors of Drug-Eluting Stent Thrombosis During and After Discontinuation of Thienopyridine Treatment Circulation, August 14, 2007; 116(7): 745 - 754. [Abstract] [Full Text] [PDF]
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R. L. Frye Update in Cardiology Ann Intern Med, August 7, 2007; 147(3): 180 - 186. [Full Text] [PDF]
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S. R. Dixon, C. L. Grines, and W. W. O'Neill The Year in Interventional Cardiology J. Am. Coll. Cardiol., July 17, 2007; 50(3): 270 - 285. [Full Text] [PDF]
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S. Kaul, P. K. Shah, and G. A. Diamond As Time Goes By: Current Status and Future Directions in the Controversy Over Stenting J. Am. Coll. Cardiol., July 10, 2007; 50(2): 128 - 137. [Abstract] [Full Text] [PDF]
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R. Jaffe and B. H. Strauss Late and Very Late Thrombosis of Drug-Eluting Stents: Evolving Concepts and Perspectives J. Am. Coll. Cardiol., July 10, 2007; 50(2): 119 - 127. [Abstract] [Full Text] [PDF]
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D. R. Holmes Jr, D. J. Kereiakes, W. K. Laskey, A. Colombo, S. G. Ellis, T. D. Henry, J. J. Popma, P. W.J.C. Serruys, T. Kimura, D. O. Williams, et al. Thrombosis and Drug-Eluting Stents: An Objective Appraisal J. Am. Coll. Cardiol., July 10, 2007; 50(2): 109 - 118. [Abstract] [Full Text] [PDF]
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S. A. Spinler and R. L. Wilensky Duration of clopidogrel therapy after placement of drug-eluting intracoronary stent Am. J. Health Syst. Pharm., July 1, 2007; 64(13): 1432 - 1434. [Full Text] [PDF]
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J. T. Dove, D. J. Moliterno, W. D. Weaver, and M. E. Shelton President's Page: Drug-Eluting Stents in Contemporary Practice--A Call for a Real-World, Open-Entry, Device-Tracking Registry J. Am. Coll. Cardiol., June 5, 2007; 49(22): 2223 - 2226. [Full Text] [PDF]
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