Mr Eduardo Alegria-Barrero
Final decision of whether a drug-eluting stent (DES) should be implanted or not is usually left in interventional cardiologists’ hands. Clinical cardiologists should become part of this decision-making process because they play a major role dealing with possible future complications.
The addition of antimitotic drugs released from polymer coatings into coronary stents has achieved a significant decrease of in-stent restenosis and a corresponding decrease in the subsequent need for new revascularisations. Furthermore, drug-eluting stents (DES) significantly reduce major adverse cardiac events. These beneficial results have lead to a widespread use of these devices in patients with increasing degrees of lesion complexity and comorbidities. After the initial experience with DES, researchers and clinicians have been faced with a new unfrequent but critical complication: DES thrombosis, accounting for 0,35-3,1%/year in patients receiving DES.
The use of DES call for prolonged dual antiplatelet therapy in order to avoid thrombus formation within the stent during the endothelisation period. Thus, many patients benefiting from less neointimal proliferation in order to prevent restenosis and susequent revascularisations, carry the risk of delayed or incomplete endothelisation, particularly after discontinuation of antiplatelet therapy (hazard ratio: 57 95% CI: 15-220). The problem increases with the dramatic drop in adherence to medication after 3 months of therapy, due to lack of medical information, reimbursement policies and many other factors.
Additionally, patients undergoing percutaneous coronary revascularisation are older, with a significant degree of comorbidities which complicate medical decisions and require special attention (multiple drug regimens, reduced mobility, risk of falling, risk of urgent trauma surgeries, gastrointestinal complications).
Clinical cardiologists consider percutaneous revascularisation for their patients to achieve longer survival and better symptom relief. In some clinical scenarios, complex patients undergo coronary revascularisation with one or more stents which are placed by an interventional cardiologist that decides which stent is suitable for the patient.
The decision whether to implant a BMS or a DES is taken in most instances exclusively by the interventional cardiologist, who usually does not assume patient follow-up and does not tackle the possible complications.
There are some accepted situations in which DES have demonstrated in clinical trials to be clearly superior to BMS (“on-label indications”): stable/unstable angina, single de novo lesions in native vessels, diameter 2,5-3,75 mm and length up to 28 mm and coronary arteries supplying a large area of jeopardised myocardium (proximal anterior descending artery or total chronic occlusion). Despite these indications, some interventional cardiologists also accept DES use in other situations, for instance myocardial infarction, high-risk acute coronary syndromes, systolic dysfunction, bifurcations, chronic total occlusions, saphenous venous grafts, multi-vessel disease, diabetics and left main stenoses, based on their experience or on non-evidence based anatomical or clinical reasons (the so-called “off-label indications”). BMS are currently widely used in simple or short lesions involving vessels above than 3mm in diameter.
The decision regarding stent implantation and the corresponding oral anticoagulant/antiplatelet treatment in different clinical scenarios should be based on a stepped approach (see Figure 1). First of all, we should consider the risk of bleeding inherent to that particular patient. This risk can be classified as low, medium or high according to some patient characteristics and the likelihood of some planned/unplanned future surgeries. Table 1 lists some of the frequently performed procedures in which there exist a high risk of bleeding and, as a result, a conflict can arise between the need for intensive antithrombotic therapy and the surgical risk of bleeding. In the low-risk category, among others, can be included dermatologic, dental (perhaps with the exception of wisdom tooth extraction), ophthalmologic, and arthroscopic interventions. Evidence exists that significant bleeding complications are very unusual in those procedures in which blood loss is scarce or is easy to control by local haemostatic measures. Therefore, these procedures can be performed safely on dual antiplatelet therapy.
The second consideration is the risk of thromboembolic complications, including coronary events and specifically in-stent thrombosis. In patients with a high thromboembolic risk (Table 2), especially if bleeding risk is also significant, DES implantation should be carefully evaluated and comprehensive decision made by both clinical and interventional cardiologists.
There are some remaining questions that will be answered in future studies:
Future techniques analysing antiplatelets' effect, safer DES, better antiplatelet regimens and better medical knowledge will help reduce thrombotic and bleeding complications resulting from coronary artery revascularisation.
Figure 1 summarises the general approach in terms of oral antiplatelet and anticoagulant treatment in patients receiving DES and BMS:
Table 1 : Some diagnostic and surgical procedures with a high bleeding risk
Intracranial and spinal cord surgery
Abdominal aneurysm resection
Major peripheral vascular surgery
Extensive cancer surgery (neural, urogenital, cervical, abdominal, breast)
Major orthopaedic surgery (hip and knee replacement, laminectomy)
Extensive reconstructive plastic surgery
Transurethral resection and bladder interventions
Solid organ biopsy
Table 2: Some clinical scenarios with a high thromboembolic risk
Previous venous thromboembolic event (< 3 months)
Atrial fibrillation with a previous embolic event
Mechanical cardiac prosthesis
Thrombophylic disease (congenital or acquired)
Acute myocardial infarction (< 3 months)
Ischemic stroke (< 1 month)
Figure 1: Algorythm for the management of anticoagulant-antiplatelet therapy in patients receiving coronary stents. ASA: acetyl salicylic acid; OAC: oral anticoagulant treatment; BMS: bare metal stents; DES: drug eluting stents; CABG: coronary bypass surgery. * 1 year after an acute coronary syndrome ** Clopi + OAC also possible*** Avoid DES if possible.
Practical guidelines are the following :
Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, et al, American College of Chest Physicians. The perioperative management of antithrombotic therapy. American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest 2008;133(6 Suppl):299-339S.
Hirsh J. Guidelines for antithrombotic therapy. 8th edition. Hamilton: Dekker, 2008:37-44.
Holmes DR, Kereiakes DJ, Laskey WK, Colombo A, Ellis SG, Henry TD, et al. Thrombosis and drug-eluting stents: an objective appraisal. J Am Cardiol 2007;50(2):109-18.
Moreno R, Fernandez C, Hernandez R, Alfonso F, Angiolillo DJ, Sabate M et al. Drug-eluting stent thrombosis. J Am Cardiol 2005;45:954-9.
Qasim A, Cosgrave J, Lativ A, Colombo A. Long term follow-up of drug-eluting stents when insert for on- and off- label indications. J Am Cardiol 2007;100(11):1619-24. C, Rodriguez-Alemparte M, Berrocal D, et al. Coronary stent thrombosis in the current drug-eluting stent era: insights from the ERACI III Trial. J Am Cardiol 2006;47:205-15.
Stettler C, Wandel S, Alleman S, Kastrati A, Morice M-C, Schömig A, et al. Outcomes associated with drug-eluting stents and bare metal stents: a collaborative network metanalysis.
Thachil J, Gatt A, Martlew V. Management of surgical patients receiving anticoagulation and antiplatelet agents. Br J Surg 2008;95:1437-48.
Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, Filippatos G. Acute Myocardial Infarction in patients presenting with ST-segment elevation (Management of). ESC Clinical Practice Guidelines. Eur Heart J 2008;29:2909-45.
E Alegría Barrero1, R Moreno2 1Cardiology and Cardiovascular Surgery. Rotger Clinic. Palma de Mallorca, Spain. 2Cardiology Department. La Paz Hospital. Madrid, Spain. Eduardo Alegría Barrero Instituto de Cardiología (Hemodinámica) Clínica Rotger c/ Santiago Russiñol, 9 07012 - Palma de Mallorca, Spain Tel. +34 971 44 85 02 Fax +34 971 72 90 66 firstname.lastname@example.org
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