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Very Late Stent Thrombosis After Dual Antiplatelet Therapy Discontinuation in a Patient with a History of Acute Stent Thrombosis

Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA

Thomas H Hauser, MD MMSc MPH FACC

Director of Nuclear Cardiology, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School, Boston

Reprints: Dr. Bhatt, 179 Longwood Ave., Boston, MA 02115, fax 617/732-2244, snehal.bhatt{at}mcphs.edu

OBJECTIVE: To describe a case of very late stent thrombosis after dual antiplatelet discontinuation in a patient with a previous history of stent thrombosis.

CASE SUMMARY: A 62-year-old man with a history of coronary artery disease, multiple acute coronary syndromes requiring percutaneous coronary interventions with multiple stent placements, and acute stent thrombosis resulting in ST segment elevation myocardial infarction presented to the hospital with chest pain. The chest pain was not relieved by 4 sublingual nitroglycerin tablets. Five days prior to his presentation, the patient had been instructed to discontinue both aspirin and clopidogrel in preparation for a left ankle fusion procedure. He was taken to the cardiac catheterization laboratory where he was found to have thrombosis in a sirolimus-eluting stent placed more than 3 years ago. Thrombectomy and balloon angioplasty were performed, and the patient completed his hospital course without complications.

DISCUSSION: Stent thrombosis associated with drug-eluting stents is a complicated pathophysiologic phenomenon with multiple patient-, procedure-, and device-related factors. Application of these risk factors to quantify the risk of stent thrombosis as they apply to a single patient is unknown. Discontinuation of recommended dual antiplatelet therapy with aspirin plus a thienopyridine has been identified as a major risk factor for stent thrombosis, but the optimal duration of dual antiplatelet therapy remains unknown. Current recommendations suggest extending dual antiplatelet therapy beyond one year in patients with low bleeding risk.

CONCLUSIONS: Given the overall data at this time and the severity of stent thrombosis, it seems prudent to continue dual antiplatelet therapy with aspirin indefinitely plus a thienopyridine for at least one year, with continuation beyond one year on a case-by-case basis depending on the risks of in-stent thrombosis and bleeding. In patients with a low risk of bleeding, indefinite continuation of dual antiplatelet therapy may be reasonable.

Key Words: aspirin, clopidogrel, thienopyridine, very late stent thrombosis

Published Online, April 1, 2008. www.theannals.com, DOI 10.1345/aph.1K647