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(Circulation. 2009;119:687-698.)
© 2009 American Heart Association, Inc.

Interventional Cardiology

Early Stent Thrombosis in Patients With Acute Coronary Syndromes Treated With Drug-Eluting and Bare Metal Stents

The Acute Catheterization and Urgent Intervention Triage Strategy Trial

Jiro Aoki, MD; Alexandra J. Lansky, MD; Roxana Mehran, MD; Jeffery Moses, MD; Michel E. Bertrand, MD; Brent T. McLaurin, MD; David A. Cox, MD; A. Michael Lincoff, MD; E. Magnus Ohman, MD; Harvey D. White, DSc; Helen Parise, ScD; Martin B. Leon, MD; Gregg W. Stone, MD

From Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (J.A., A.J.L., R.M., J.M., H.P., M.B.L., G.W.S.); Hôpital Cardiologique, Lille, France (M.E.B.); AnMed Health, Anderson, SC (B.T.M.); Mid Carolina Cardiology, Charlotte, NC (D.A.C.); Cleveland Clinic, Cleveland, Ohio (A.M.L.); Duke University Medical Center, Durham, NC (E.M.O.); and Auckland City Hospital, Auckland, New Zealand (H.D.W.).

Correspondence to Gregg W. Stone, MD, 161 Ft Washington Ave, 5th Floor, New York, NY 10032. E-mail gs2184{at}columbia.edu

Received July 3, 2008; accepted November 12, 2008.

Background— The clinical and angiographic predictors of early (<30 days) stent thrombosis (ST) have not been reported in high-risk patients with acute coronary syndromes.

Methods and Results— Qualitative and quantitative coronary angiographic analyses were performed in 3405 patients with moderate- and high-risk acute coronary syndromes in whom stents were implanted in the prospective randomized Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial, including 3043 patients (89.4%) in whom drug-eluting stents were implanted. Within 30 days, definite or probable ST occurred in 48 patients (1.4%). ST rates were not significantly different in patients treated with bare metal stents compared with drug-eluting stents (1.4% versus 1.4%; P=1.00) or with heparin plus glycoprotein IIb/IIIa inhibitors (1.1%) compared with bivalirudin with or without IIb/IIIa inhibitors (1.6% and 1.5%, respectively; P=0.26 and P=0.37, respectively). Compared with patients without ST, patients with ST more frequently had insulin-requiring diabetes mellitus and baseline renal insufficiency, a greater overall burden of coronary atherosclerosis, and suboptimal final angiographic results. ST also was more common in patients without preprocedural thienopyridine administration and with inconsistent antiplatelet drug use within 30 days. By multivariable analysis, the strongest independent predictors of definite ST were a smaller final stent minimal lumen diameter, a lack of preprocedural thienopyridine administration, the extent of coronary artery disease, and higher baseline hemoglobin level.

Conclusions— Occurring in nearly 1 in 70 patients, early ST is relatively common in acute coronary syndromes, occurs with similar frequency after anticoagulation with either heparin plus glycoprotein IIb/IIIa inhibitors or bivalirudin with or without IIb/IIIa inhibitors, and is predicted by diffuse atherosclerosis, suboptimal angiographic results, and inadequate pharmacotherapy.

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