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Ioannis Iakovou, MD; Thomas Schmidt, MD; Erminio Bonizzoni, PhD; Lei Ge, MD; Giuseppe M. Sangiorgi, MD; Goran Stankovic, MD; Flavio Airoldi, MD; Alaide Chieffo, MD; Matteo Montorfano, MD; Mauro Carlino, MD; Iassen Michev, MD; Nicola Corvaja, MD; Carlo Briguori, MD; Ulrich Gerckens, MD; Eberhard Grube, MD; Antonio Colombo, MD

JAMA. 2005;293:2126-2130.

ABSTRACT
Context  Traditionally, stent thrombosis has been regarded as a complication of percutaneous coronary interventions during the first 30 postprocedural days. However, delayed endothelialization associated with the implantation of drug-eluting stents may extend the risk of thrombosis beyond 30 days. Data are limited regarding the risks and the impact of this phenomenon outside clinical trials.

Objective  To evaluate the incidence, predictors, and clinical outcome of stent thrombosis after implantation of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice.

Design, Setting, and Patients  Prospective observational cohort study conducted at 1 academic hospital and 2 community hospitals in Germany and Italy. A total of 2229 consecutive patients underwent successful implantation of sirolimus-eluting (1062 patients, 1996 lesions, 2272 stents) or paclitaxel-eluting (1167 patients, 1801 lesions, 2223 stents) stents between April 2002 and January 2004.

Interventions  Implantation of a drug-eluting stent (sirolimus or paclitaxel). All patients were pretreated with ticlopidine or clopidogrel and aspirin. Aspirin was continued indefinitely and clopidogrel or ticlopidine for at least 3 months after sirolimus-eluting and for at least 6 months after paclitaxel-eluting stent implantation.

Main Outcome Measures  Subacute thrombosis (from procedure end through 30 days), late thrombosis (>30 days), and cumulative stent thrombosis.

Results  At 9-month follow-up, 29 patients (1.3%) had stent thrombosis (9 [0.8%] with sirolimus and 20 [1.7%] with paclitaxel; P = .09). Fourteen patients had subacute thrombosis (0.6%) and 15 patients had late thrombosis (0.7%). Among these 29 patients, 13 died (case fatality rate, 45%). Independent predictors of stent thrombosis were premature antiplatelet therapy discontinuation (hazard ratio [HR],  89.78; 95% CI, 29.90-269.60; P<.001), renal failure (HR,  6.49; 95% CI, 2.60-16.15; P<.001), bifurcation lesions (HR,  6.42; 95% CI, 2.93-14.07; P<.001), diabetes (HR,  3.71; 95% CI, 1.74-7.89; P = .001), and a lower ejection fraction (HR,  1.09; 95% CI, 1.05-1.36; P<.001 for each 10% decrease).

Conclusions  The cumulative incidence of stent thrombosis 9 months after successful drug-eluting stent implantation in consecutive "real-world" patients was substantially higher than the rate reported in clinical trials. Premature antiplatelet therapy discontinuation, renal failure, bifurcation lesions, diabetes, and low ejection fraction were identified as predictors of thrombotic events.

INTRODUCTION

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Despite major improvements in antiplatelet therapy, thrombotic events remain the primary cause of death after percutaneous coronary interventions.^1-2 Sirolimus-eluting stents and polymer-based paclitaxel-eluting stents have been shown to reduce neointimal hyperplasia and risk of restenosis without increasing the risk of stent thrombosis.^3-7 Operators are now using drug-eluting stents for a wide variety of clinical and anatomic situations, many of which have not been evaluated in randomized studies.^8-10 We analyzed the incidence, predictors, and clinical outcome of stent thrombosis at 9-month follow-up in an observational cohort study.

METHODS

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We identified 2229 consecutive patients who underwent successful implantation with sirolimus-eluting stents (1062 patients, 1996 lesions, 2272 stents) or paclitaxel-eluting stents (1167 patients, 1801 lesions, 2223 stents) between April 2002 and January 2004. Patients were treated at 2 community hospitals or 1 academic hospital in Germany and Italy. Patients with ST-elevation acute myocardial infarction (MI) less than 48 hours before the procedure, with intraprocedural stent thrombosis, and those treated with both types of stents were excluded. All patients were pretreated with ticlopidine or clopidogrel and aspirin; a loading dose of 300 mg of clopidogrel was given to patients not previously taking the agent. Aspirin was continued indefinitely and clopidogrel or ticlopidine for at least 3 months after sirolimus-eluting stent implantation and for at least 6 months after paclitaxel-eluting stent implantation. Stent implantation methods have been described previously.¹¹ Glycoprotein IIb/IIIa inhibitors were administered at the physician’s discretion. Standard qualitative and quantitative analyses and definitions were used for the angiographic analysis.¹²

All patients signed an informed consent document and local institutional review boards approved the study as planned.

Clinical Definitions and Follow-up

Stent thrombosis was determined as the occurrence of any of the following events: angiographic documentation of partial or total stent occlusion detected within 30 days of the procedure (an acute clinical ischemic event in addition to angiographic documentation had to be present when the event occurred after 30 days), or sudden cardiac death or postprocedural MI after successful stent implantation not clearly attributable to another coronary lesion. Stent thrombosis cases were categorized according to the timing of occurrence into subacute (from procedure end through 30 days) and late (>30 days).

Major adverse cardiac events were defined as death (all-cause), Q-wave MI, target lesion revascularization, and target vessel revascularization.

Statistical Analysis

Differences in proportions were tested with the ² or Fisher exact test. SAS version 8.2 (SAS Institute Inc, Cary, NC) was used for data analysis.

A total sample of 2300 observations was computed to achieve 80% power at a 2-sided .05 significance level to detect a hazard ratio (HR) equal to or greater than 3.0 with a Cox regression of the log HR on a binary risk factor with a 25% or greater prevalence. The sample size was adjusted for an anticipated event rate of 1.5%.

Relationships of event incidence to covariates were investigated with univariate Cox regression models. The proportional hazard assumption was checked for all screened covariates and no relevant violations were found. The predictive robustness of univariate findings was subsequently tested by means of a bootstrap subset selection method in which multivariable Cox regression analysis using a stepwise elimination process was repeated for each of 1000 bootstrap samples.¹³ The relative frequency of selection of "important" variables was used as a criterion for inclusion of predictors in the final multivariable model. Variables were retained if the selection frequency of the bootstrap samples was at least 50% or if they were clinically relevant. Because of the small absolute number of events, we performed an internal validation process to test model adequacy and quantify "overfitting."¹⁴

The proportion of total variability was estimated by means of the Nagelkerke Index (pseudo R²), which was calculated when the models were fitted to 1000 bootstrap replications (training sample) and to the original data (test sample). The Nagelkerke Index obtained from each bootstrap sample was then subtracted from the initial index value of the original population. The average of the differences was considered as a measure of optimism in the model fit, where optimism is the proportion of variability ascribed to overfitting. Finally, a corrected index was calculated by subtracting the average of the optimism estimates from the original Nagelkerke Index. The estimates of slope shrinkage, which were used to identify overparameterized models, were obtained for the multivariable models using the same bootstrapping validation process. Thus we were reassured that, although based on few events, overfitting did not substantially bias our final model.

RESULTS

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Baseline Characteristics and In-Hospital Outcomes

Baseline, angiographic, and procedural characteristics are shown in Table 1. All stents were deployed successfully. There were no significant differences between the 2 stent groups regarding procedural complications and in-hospital outcome. The rates for Q-wave and non–Q-wave MI were 0.3% and 9%, respectively. There were 4 in-hospital deaths, of which 2 were determined to be caused by stent thrombosis.

View this table: [in this window] [in a new window] Table 1. Baseline Clinical, Angiographic, and Procedural Characteristics According to Stent Type

Incidence, Timing, Presentation, and Clinical Outcome of Stent Thrombosis

At 9-month follow-up (available in all patients), 29 patients (1.3%) had stent thrombosis (9 [0.8%] in the sirolimus group and 20 [1.7%] in the paclitaxel group; P = .09). Fourteen patients had subacute thrombosis (0.6%), 4 in the sirolimus group and 10 in the paclitaxel group (0.4% vs 0.8%; P = .19) and 15 patients had late thrombosis (0.7%), 5 in the sirolimus group and 10 in the paclitaxel group (0.5% vs 0.8%; P = .30).

A total of 71% (10/14) of the subacute cases occurred within 1 week of the procedure (median, 4 days) and 53% (8/15) of the late thrombosis cases occurred within 3 months of the procedure (median, 57 days). Seven cases (24%) presented as death, 20 (69%) as nonfatal MI, and 2 (7%) as unstable angina.

At follow-up the case-fatality rate—including death at presentation—was 45% (13/29). Angiographic documentation of thrombosis was available in 12 of the 22 patients (55%) with stent thrombosis (including both patients that presented with unstable angina) that did not present with death. In-hospital data were available for all patients who presented with acute MI and had no angiographic evidence of stent thrombosis.

At 9-month follow-up, target lesion revascularization was performed in 141 patients (6.3%) (58 [5.5%] in the sirolimus group vs 83 [7.1%] in the paclitaxel group; P = .13). Major adverse cardiac events occurred in 242 patients (10.8%) (109 [10.3%] in the sirolimus group vs 133 [11.4%] in the paclitaxel group; P = .42).

Predictors of Stent Thrombosis

The incidence of stent thrombosis according to selected patient characteristics and the univariate predictors of cumulative stent thrombosis are shown in Table 2. Five of 17 patients with premature antiplatelet therapy discontinuation had stent thrombosis; in 1 of them only clopidogrel was discontinued. Independent predictors of subacute, late, and cumulative stent thrombosis are shown in Table 3. The key predictors of stent thrombosis were premature antiplatelet therapy discontinuation, renal failure, bifurcation lesions, diabetes, and low ejection fraction. For subacute thrombosis, stent length was also a predictor: for each 1-mm increase in length, there was 1.03 times greater risk of thrombosis.

View this table: [in this window] [in a new window] Table 2. Univariate Predictors of Cumulative Stent Thrombosis

View this table: [in this window] [in a new window] Table 3. Independent Predictors of Stent Thrombosis

COMMENT

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In a large cohort of consecutive patients undergoing drug-eluting stent implantation, we noted a 9-month cumulative stent thrombosis incidence of 1.3%, substantially higher than rates reported in major clinical trials (0.4% at 1 year for sirolimus and 0.6% at 9 months for paclitaxel).^{3, 5} With widespread availability of drug-eluting stents, the scope of percutaneous coronary intervention has been expanded to more complex lesions and patients. In our study, 27% of the population had diabetes and 79% of the lesions were complex. The clinical consequences of stent thrombosis were severe, with a case-fatality rate of 45%.

Similar to previous reports of both bare-metal stents^{2, 16-17} and drug-eluting stents,^18-19 our study found that premature discontinuation of antiplatelet therapy was the most important predictor of stent thrombosis after implantation. Thrombosis occurred in 29% of patients who prematurely discontinued dual antiplatelet therapy, making treatment adherence of paramount importance. Nonetheless, the absolute numbers of events in our cohort were small, leading to wide confidence intervals for estimation of effect magnitude.

In addition to premature discontinuation of antiplatelet therapy, other key predictors of stent thrombosis were renal failure, bifurcation lesions, diabetes, low ejection fraction, and, for subacute thrombosis, stent length.

Renal failure has been linked to cardiac disease with microvascular and metabolic abnormalities that may predispose to thrombus formation.^20-21 Renal failure also has been associated by numerous studies with an increased mortality rate despite successful coronary intervention.^22-24

Regarding bifurcational lesion location, pathology studies have suggested that arterial branch points are foci of low shear and low flow velocity and are sites predisposed to the development of atherosclerotic plaque, thrombus, and inflammation.^25-27 The observed associations of diabetes,^28-32 low ejection fraction,^{2, 33} and stent length² with stent thrombosis are also consistent with previous reports.

In our study, stent type did not emerge as an independent predictor of thrombosis. Of concern, however, we found an almost double incidence of stent thrombosis after paclitaxel compared with sirolimus stent implantation. These findings are consistent with those of the ISAR-DESIRE (Intracoronary Stenting and Antithrombotic Regimen–Drug-Eluting Stents for In-Stent Restenosis) trial of drug-eluting stents for in-stent restenosis, in which sirolimus-eluting stents tended to be associated with a better outcome than paclitaxel-eluting stents.⁶ However, without larger numbers it is difficult to make firmconclusions; subsequent randomized trials will be critically important.

A limitation of the current study was the lack of angiographic documentation in all cases adjudicated as stent thrombosis. Nevertheless, the definition of stent thrombosis that we proposed is similar to the one used in important recent studies extended beyond 30 days.^{3, 19}

In conclusion, the incidence of stent thrombosis at 9 months after successful drug-eluting stent implantation in consecutive real-world patients was 1.3%. Premature antiplatelet therapy discontinuation, bifurcation lesions, and low ejection fraction were identified as independent predictors of subacute, late, and cumulative stent thrombosis. In addition, stent length was also recognized as a predictor of subacute thrombosis, and renal failure and diabetes as predictors of both subacute and cumulative stent thrombosis. The clinical consequences were death in 45% of patients and nonfatal MI in the majority of the others.

AUTHOR INFORMATION

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Corresponding Author: Antonio Colombo, MD, EMO Centro Cuore Columbus, 48 Via M Buonarroti, 20145 Milan, Italy (info{at}emocolumbus.it).

Author Contributions: Dr Colombo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Iakovou, Schmidt, Colombo.

Acquisition of data: Ge, Sangiorgi, Stankovic, Airoldi, Chieffo, Montorfano, Carlino, Michev, Corvaja, Gerckens, Grube.

Analysis and interpretation of data: Iakovou, Bonizzoni, Briguori.

Drafting of the manuscript: Iakovou, Colombo.

Critical revision of the manuscript for important intellectual content: Schmidt, Bonizzoni, Ge, Sangiorgi, Stankovic, Airoldi, Chieffo, Montorfano, Carlino, Michev, Corvaja, Briguori, Gerckens, Grube.

Statistical analysis: Iakovou, Bonizzoni.

Study supervision: Schmidt, Sangiorgi, Chieffo, Montorfano, Carlino, Briguori, Gerckens, Grube, Colombo.

Financial Disclosures: None reported.

Previous Presentation: This study was presented at the American Heart Association Scientific Sessions; November 7-10, 2004; New Orleans, La.

Author Affiliations: Centro Cuore Columbus and San Raffaele Hospital, Milan, Italy (Drs Iakovou, Ge, Sangiorgi, Stankovic, Airoldi, Chieffo, Montorfano, Carlino, Michev, Corvaja, Briguori, and Colombo); Mediolanum Cardio Research, Milan, Italy (Dr Sangiorgi); Department of Cardiology, Klinikum Siegburg Rhein-Sieg GmbH, Siegburg, Germany (Drs Schmidt, Gerckens, and Grube); and Institute of Medical Statistics and Biometry, University of Milan, Milan, Italy (Dr Bonizzoni).

REFERENCES

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Randomized Comparison of the Nobori Biolimus A9-Eluting Coronary Stent With the Taxus Liberte Paclitaxel-Eluting Coronary Stent in Patients With Stenosis in Native Coronary Arteries: The NOBORI 1 Trial--Phase 2
Chevalier et al.
Circ Cardiovasc Interv 2009;2:188-195.
ABSTRACT | FULL TEXT  

Update on dual antiplatelet therapy for percutaneous coronary intervention
Prasad and Holmes
Heart 2009;95:861-865.
FULL TEXT  

Safety and effectiveness of drug-eluting and bare-metal stents for patients with off- and on-label indications.
Ko et al.
J Am Coll Cardiol 2009;53:1773-1782.
ABSTRACT | FULL TEXT  

Long-Term Safety and Efficacy of Drug-Eluting versus Bare-Metal Stents in Sweden
James et al.
NEJM 2009;360:1933-1945.
ABSTRACT | FULL TEXT  

Use of drug-eluting stents in acute myocardial infarction: a systematic review and meta-analysis.
Brar et al.
J Am Coll Cardiol 2009;53:1677-1689.
ABSTRACT | FULL TEXT  

Unprotected Left Main Stenting in the Real World: Two-Year Outcomes of the French Left Main Taxus Registry
Vaquerizo et al.
Circulation 2009;119:2349-2356.
ABSTRACT | FULL TEXT  

Local Determinants of Thrombus Formation Following Sirolimus-Eluting Stent Implantation Assessed by Optical Coherence Tomography
Otake et al.
J Am Coll Cardiol Intv 2009;2:459-466.
ABSTRACT | FULL TEXT  

Reply
Lee et al.
J Am Coll Cardiol Intv 2009;2:474-475.
FULL TEXT  

Five-year follow-up after sirolimus-eluting stent implantation results of the SIRIUS (Sirolimus-Eluting Stent in De-Novo Native Coronary Lesions) Trial.
Weisz et al.
J Am Coll Cardiol 2009;53:1488-1497.
ABSTRACT | FULL TEXT  

Predictors of Coronary Stent Thrombosis: The Dutch Stent Thrombosis Registry
van Werkum et al.
J Am Coll Cardiol 2009;53:1399-1409.
ABSTRACT | FULL TEXT  

Rapamycin-Eluting Stents in the Arterial Duct: Experimental Observations in the Pig Model
Lee et al.
Circulation 2009;119:2078-2085.
ABSTRACT | FULL TEXT  

Clopidogrel in acute coronary syndromes
Chua and Ignaszewski
BMJ 2009;338:b1180-b1180.
FULL TEXT  

Restenosis Revisited
Calvert and Bennett
Circ. Res. 2009;104:823-825.
FULL TEXT  

Efficacy and safety of drug-eluting stent use in patients with atrial fibrillation
Ruiz-Nodar et al.
Eur Heart J 2009;30:932-939.
ABSTRACT | FULL TEXT  

In Vivo Assessment of High-Risk Coronary Plaques at Bifurcations With Combined Intravascular Ultrasound and Optical Coherence Tomography
Gonzalo et al.
J Am Coll Cardiol Img 2009;2:473-482.
ABSTRACT | FULL TEXT  

The Excel Stent: A Good DES, But Can We Really Stop Clopidogrel After 6 Months?
Margolis
J Am Coll Cardiol Intv 2009;2:310-311.
FULL TEXT  

Symptomatic Ostial Vertebral Artery Stenosis: Treatment with Drug-eluting Stents--Clinical and Angiographic Results at 1-year Follow-up
Yu et al.
Radiology 2009;251:224-232.
ABSTRACT | FULL TEXT  

Safety of Short-Term Discontinuation of Antiplatelet Therapy in Patients With Drug-Eluting Stents
Eisenberg et al.
Circulation 2009;119:1634-1642.
ABSTRACT | FULL TEXT  

Platelet reactivity after clopidogrel treatment assessed with point-of-care analysis and early drug-eluting stent thrombosis.
Sibbing et al.
J Am Coll Cardiol 2009;53:849-856.
ABSTRACT | FULL TEXT  

Improving clinical outcomes by reducing bleeding in patients with non-ST-elevation acute coronary syndromes
Budaj et al.
Eur Heart J 2009;30:655-661.
ABSTRACT | FULL TEXT  

Mini-Crush Versus T-Provisional Techniques in Bifurcation Lesions: Clinical and Angiographic Long-Term Outcome After Implantation of Drug-Eluting Stents
Galassi et al.
J Am Coll Cardiol Intv 2009;2:185-194.
ABSTRACT | FULL TEXT  

Percutaneous Coronary Intervention Treatment of Bifurcation Lesions--A Work in Progress: The Importance of Single-Center Studies
Kaplan
J Am Coll Cardiol Intv 2009;2:195-196.
FULL TEXT  

3-Year Comparison of Drug-Eluting Versus Bare-Metal Stents
Applegate et al.
J Am Coll Cardiol Intv 2009;2:231-239.
ABSTRACT | FULL TEXT  

Antiplatelet Therapy and Stent Thrombosis After Sirolimus-Eluting Stent Implantation
Kimura et al.
Circulation 2009;119:987-995.
ABSTRACT | FULL TEXT  

Long-Term Clinical Outcome After a First Angiographically Confirmed Coronary Stent Thrombosis: An Analysis of 431 Cases
van Werkum et al.
Circulation 2009;119:828-834.
ABSTRACT | FULL TEXT  

Early Stent Thrombosis: Past, Present, and Future
Cook and Windecker
Circulation 2009;119:657-659.
FULL TEXT  

Randomized Comparison of Everolimus-Eluting and Paclitaxel-Eluting Stents: Two-Year Clinical Follow-Up From the Clinical Evaluation of the Xience V Everolimus Eluting Coronary Stent System in the Treatment of Patients With De Novo Native Coronary Artery Lesions (SPIRIT) III Trial
Stone et al.
Circulation 2009;119:680-686.
ABSTRACT | FULL TEXT  

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
Aoki et al.
Circulation 2009;119:687-698.
ABSTRACT | FULL TEXT  

Interindividual variability in the response to oral antiplatelet drugs: a position paper of the Working Group on antiplatelet drugs resistance appointed by the Section of Cardiovascular Interventions of the Polish Cardiac Society, endorsed by the Working Group on Thrombosis of the European Society of Cardiology
Kuliczkowski et al.
Eur Heart J 2009;30:426-435.
ABSTRACT | FULL TEXT  

Drug-eluting stent thrombosis
Stahli et al.
Ther Adv Cardiovasc Dis 2009;3:45-52.
ABSTRACT  

Mortality following placement of drug-eluting and bare-metal stents for ST-segment elevation acute myocardial infarction in the Global Registry of Acute Coronary Events
Steg et al.
Eur Heart J 2009;30:321-329.
ABSTRACT | FULL TEXT  

Percutaneous Revascularization of Grafts Versus Native Coronary Arteries in Postcoronary Artery Bypass Graft Patients
Garcia-Tejada et al.
ANGIOLOGY 2009;60:60-66.
ABSTRACT  

Expanding the Recognition and Assessment of Bleeding Events Associated With Antiplatelet Therapy in Primary Care
Cohen
Mayo Clin Proc. 2009;84:149-160.
ABSTRACT | FULL TEXT  

Late stent malapposition risk is higher after drug-eluting stent compared with bare-metal stent implantation and associates with late stent thrombosis
Hassan et al.
Eur Heart J 2009;0:ehn553v1-9.
ABSTRACT | FULL TEXT  

Are drug-eluting stents safe in the long term?
Genereux and Mehran
CMAJ 2009;180:154-155.
FULL TEXT  

Randomized Study of the Crush Technique Versus Provisional Side-Branch Stenting in True Coronary Bifurcations: The CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents) Study
Colombo et al.
Circulation 2009;119:71-78.
ABSTRACT | FULL TEXT  

Meeting Report: ESC Forum on Drug Eluting Stents European Heart House, Nice, 27-28 September 2007
Authors/writing members: et al.
Eur Heart J 2009;30:152-161.
FULL TEXT  

An Appraisal of Dual Antiplatelet Therapy with Clopidogrel and Aspirin for Prevention of Cardiovascular Events
Terpening
J Am Board Fam Med 2009;22:51-56.
ABSTRACT | FULL TEXT  

Antiplatelet Agents in the Perioperative Period
O'Riordan et al.
Arch Surg 2009;144:69-76.
ABSTRACT | FULL TEXT  

In-Hospital and 1-Year Outcomes Among Percutaneous Coronary Intervention Patients With Chronic Kidney Disease in the Era of Drug-Eluting Stents: A Report From the EVENT (Evaluation of Drug Eluting Stents and Ischemic Events) Registry
Latif et al.
J Am Coll Cardiol Intv 2009;2:37-45.
ABSTRACT | FULL TEXT  

Endothelialization and late stent thrombosis in diabetics.
Kaneda
J Am Coll Cardiol 2008;52:2213-2213.
FULL TEXT  

Current Status of Percutaneous Coronary Intervention With Drug-Eluting Stents in Asia
Park and Kim
Circulation 2008;118:2730-2737.
FULL TEXT  

Angiographic and clinical outcome of invasively managed patients with thrombosed coronary bare metal or drug-eluting stents: the OPTIMIST study
Burzotta et al.
Eur Heart J 2008;29:3011-3021.
ABSTRACT | FULL TEXT  

Coronary Artery Bypass Grafting Versus Stenting for Unprotected Left Main Coronary Artery Disease: Where Lies the Body of Proof?
Shemin
Circulation 2008;118:2326-2329.
FULL TEXT  

Should dual antiplatelet therapy after drug-eluting stents be continued for more than 1 year?: Dual Antiplatelet Therapy After Drug-Eluting Stents Should Be Continued for More Than One Year and Preferably Indefinitely
Chhatriwalla and Bhatt
Circ Cardiovasc Interv 2008;1:217-225.
FULL TEXT  

Should dual antiplatelet therapy after drug-eluting stents be continued for more than 1 year?: Dual Antiplatelet Therapy After Drug-Eluting Stents Should Not Be Continued for More Than 1 Year and Preferably Indefinitely
Colombo and Gerber
Circ Cardiovasc Interv 2008;1:226-232.
FULL TEXT  

Culotte stenting technique in coronary bifurcation disease: angiographic follow-up using dedicated quantitative coronary angiographic analysis and 12-month clinical outcomes
Adriaenssens et al.
Eur Heart J 2008;29:2868-2876.
ABSTRACT | FULL TEXT  

Comparison of Percutaneous Coronary Intervention With Bare-Metal and Drug-Eluting Stents for Cardiac Allograft Vasculopathy
Lee et al.
J Am Coll Cardiol Intv 2008;1:710-715.
ABSTRACT | FULL TEXT  

Coronary stent thrombosis in the perioperative period
Cruden et al.
BMJ 2008;337:a2074-a2074.
FULL TEXT  

Long-Term Clinical Outcomes After Drug-Eluting and Bare-Metal Stenting in Massachusetts
Mauri et al.
Circulation 2008;118:1817-1827.
ABSTRACT | FULL TEXT  

Management of Patients After Percutaneous Coronary Interventions
Shoulders-Odom
Crit Care Nurse 2008;28:26-40.
FULL TEXT  

Acute and long-term outcome of unprotected left main coronary angioplasty compared to the anticipated surgical risk
Rademacher et al.
ICVTS 2008;7:871-877.
ABSTRACT | FULL TEXT  

Stent Thrombosis, Clinical Events, and Influence of Prolonged Clopidogrel Use After Placement of Drug-Eluting Stent: Data From an Observational Cohort Study of Drug-Eluting Versus Bare-Metal Stents
Park et al.
J Am Coll Cardiol Intv 2008;1:494-503.
ABSTRACT | FULL TEXT  

Incidence and Correlates of Drug-Eluting Stent Thrombosis in Routine Clinical Practice: 4-Year Results From a Large 2-Institutional Cohort Study
Wenaweser et al.
J Am Coll Cardiol 2008;52:1134-1140.
ABSTRACT | FULL TEXT  

Long-Term Impact of Drug-Eluting Stents Versus Bare-Metal Stents on All-Cause Mortality
Shishehbor et al.
J Am Coll Cardiol 2008;52:1041-1048.
ABSTRACT | FULL TEXT  

Percutaneous Coronary Intervention for Stable Coronary Artery Disease
Katritsis and Meier
J Am Coll Cardiol 2008;52:889-893.
ABSTRACT | FULL TEXT  

Late Stent Thrombosis After Drug-Eluting Stent Implantation for Acute Myocardial Infarction: A New Red Flag Is Raised
Pfisterer
Circulation 2008;118:1117-1119.
FULL TEXT  

Delayed Arterial Healing and Increased Late Stent Thrombosis at Culprit Sites After Drug-Eluting Stent Placement for Acute Myocardial Infarction Patients: An Autopsy Study
Nakazawa et al.
Circulation 2008;118:1138-1145.
ABSTRACT | FULL TEXT  

A randomized study assessing the impact of cilostazol on platelet function profiles in patients with diabetes mellitus and coronary artery disease on dual antiplatelet therapy: results of the OPTIMUS-2 study
Angiolillo et al.
Eur Heart J 2008;29:2202-2211.
ABSTRACT | FULL TEXT  

Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures
Veitch et al.
Gut 2008;57:1322-1329.
FULL TEXT  

A Randomized Comparison of Sirolimus- Versus Paclitaxel-Eluting Stent Implantation in Patients With Diabetes Mellitus
Lee et al.
J Am Coll Cardiol 2008;52:727-733.
ABSTRACT | FULL TEXT  

Incidence and Clinical Impact of Dual Nonresponsiveness to Aspirin and Clopidogrel in Patients With Drug-Eluting Stents
Gori et al.
J Am Coll Cardiol 2008;52:734-739.
ABSTRACT | FULL TEXT