Upload
joan-thorn
View
222
Download
2
Tags:
Embed Size (px)
Citation preview
Prevalence, Predictors, and Long-Term Prognosis of Premature Discontinuation of Oral Antiplatelet Therapy After Drug Eluting Stent Implantation
Roberta Rossini, MD, PhD, Davide Capodanno, MD, Corrado Lettieri, MD, Giuseppe Musumeci, MD, Tamar Nijaradze, MD, Michele Romano, MD, Nikoloz Lortkipanidze, MD, Nicola Cicorella, MD, Giuseppe Biondi Zoccai, MD, Vasile Sirbu, MD,
Antonio Izzo, MD, Giulio Guagliumi, MD, Orazio Valsecchi, MD, Antonello Gavazzi, MD and Dominick J. Angiolillo, MD, PhD
USC Cardiologia, Dipartimento Cardiovascolare, Ospedali Riuniti di Bergamo, Italy
Divisione di Cardiologia, Ospedale Carlo Poma, Mantova, Italy
Divisione di Cardiologia, Università di Torino, Italy
University of Florida College of Medicine- Jacksonville, Florida, US
American Journal of CardiologyVolume 107, Issue 2, Pages 186-194 (January 2011)
DOI: 10.1016/j.amjcard.2010.08.067
Copyright © 2011 Elsevier Inc. Terms and Conditions
Aim of the StudyAim of the Study
The aims of the present study were to determinethe prevalence and predictors of premature
discontinuation of long-term oral antiplatelet therapy after DES implantation and to evaluate its
effects on prognosis in relation to the time and duration of the discontinuation
MethodsMethods
We studied 1358 consecutive pts treated with DES and discharged on dual antiplatelet therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day)
Clopidogrel was maintained for 12 months
Pts were followed-up for 32.4±11.3 months
Prevalence and predictors of aspirin and/or clopidogrel discontinuation were assessed
Major adverse cardiac events (MACE), defined as death, acute coronary syndrome leading to hospitalization, and stroke, were recorded. Probable/possible/definite stent thrombosis were also recorded
86,4%
8,8% 4,8%
No discontinuation
Early discontinuation
Late discontinuation Rossini R et al. Am J Card 2011, 107: 186-194
Discontinuation Causes:
Surgery 34.5% Bleeding 21% Medical decision 17.6% Dental interventions 7.6% Economic/burocratic reasons 5.9% Anticoagulant therapy 5.0%
ResultsResults
8.8% of patients discontinued one or both antiplatelet agents within the first 12 months (early discontinuation) and 4.8% withdrew aspirin after 1 year (late discontinuation)
Predictors of Discontinuation
Early Discontinuation in-hospital major bleeding (OR=9.00, p<0.001) statins at discharge (OR=0.36, p<0.001)oral anticoagulants at discharge (OR=8.21, p<0.001)
Late Discontinuation history of prior stroke (OR=5.21, p<0.001)
Rossini R et al. Am J Card 2011, 107: 186-194
Patients who discontinued antiplatelet therapy had a higher incidence of death, MACE and stent thrombosis
MACE
%
Discontinuation and Prognosis
Rossini R et al. Am J Card 2011, 107: 186-194
Overall death and discontinuation
100
90
80
70
60
50
40
48362412
Sur
viva
l (%
)
Months
Log rank testOverall: p=0.001No discontinuation vs early discontinuation: p=0.001No discontinuation vs late discontinuation: p=0.223Early discontinuation vs late discontinuation: p=0.011No discontinuation vs early+late discontinuation: p=0.018
Late discontinuation
Early discontinuation
No discontinuation
Rossini R et al. Am J Card 2011, 107: 186-194
100100
9090
8080
7070
6060
5050
4040
4848363624241212
Sur
viva
l fre
e fr
om M
AC
E (
%)
Log rank testOverall: p=0.001No discontinuation vs early discontinuation: p=0.001No discontinuation vs late discontinuation: p=0.223Early discontinuation vs late discontinuation: p=0.011No discontinuation vs early+late discontinuation: p=0.018
Late discontinuation
Early discontinuation
No discontinuation
MACE and discontinuation
MonthsRossini R et al. Am J Card 2011, 107: 186-194
Surv
ival
fre
e fr
om S
tent
Thr
ombo
sis
(%) 100100
9090
8080
7070
6060
5050
4040484836362424121200
Log rank testOverall: p=0.031No discontinuation vs early discontinuation: p=0.015No discontinuation vs late discontinuation: p=0.175Early discontinuation vs late discontinuation: p=0.653No discontinuation vs early+late discontinuation: p=0.009
Months
Late discontinuation
Early discontinuation
No discontinuation
Stent Thrombosis and discontinuation
Rossini R et al. Am J Card 2011, 107: 186-194
Death, MACE or stent thrombosis and time of discontinuation
%
P=0.10
P=0.02
P=0.008
P for trend = 0.004
P=0.10
P=0.02
P=0.008
P for trend = 0.004P=0.10
P=0.02
P=0.008
P for trend = 0.004
Rossini R et al. Am J Card 2011, 107: 186-194
Association between thienopyridine and/or aspirin discontinuation and MACE stratified by time intervals
Discuntinuation of BothDiscuntinuation of Thienopyridines Only
Discuntinuation of Aspirin Only
No Discontinuation
P=1.0
P=0.88
P = 0.20
P=0.26
P=0.001
P = 0.24P=0.08
P=0.002
P=0.001
P=1.00
P=0.11
P = 0.07
%
Rossini R et al. Am J Card 2011, 107: 186-194
ConclusionsConclusions
• Premature discontinuation of antiplatelet therapy is relatively common, especially within the first year, and strongly associated with increased cardiovascular events, including ST and death.
• Early discontinuation of antiplatelet agents within the first year was predicted by in-hospital major bleeding, oral anticoagulant use at discharge, and the lack of statin prescription.
• Strategies to improve compliance to antiplatelet therapy in patients with greater likelihood to interrupt treatment are warranted