Thienopyridine Use Six Months after Sirolimus-Eluting Stent Implant-ation Offers No Benefit
Clinical question: What are the relative contributions of aspirin and thienopyridine on preventing stent thrombosis in patients with sirolimus-eluting stents?
Background: There are no randomized clinical trials addressing the optimal duration, or the risks associated with discontinuation, of dual-antiplatelet therapy after drug-eluting stent (DES) implantation. Nevertheless, many patients continue to be maintained on dual-antiplatelet therapy beyond one year of their index DES implantation.
Study design: Prospective multicenter observational study.
Setting: Hospitals in Japan.
Synopsis: This study observed 10,778 Japanese patients undergoing sirolimus-eluting stent implantation. Patients discontinuing both thienopyridine and aspirin had a significantly higher rate of stent thrombosis than those who continued both medications for up to 18 months. However, discontinuation of thienopyridine alone was not associated with an excess risk of stent thrombosis. Additionally, a landmark analysis of patients who were free of events at six months showed rates of death for myocardial infarction (MI) at 24 months were 4.1% for patients taking thienopyridine and 4.1% for patients not taking thienopyridine (P=0.99). Ticlodipine was the thienopyridine used by more than 95% of patients.
Hospitalists should be aware that the role thienopyridine therapy plays in reducing stent thrombosis beyond one month after implantation has not been well addressed.
Bottom line: Discontinuation of thienopyridine therapy after six months while maintaining aspirin therapy is not associated with increased risk of stent thrombosis in patients with sirolimus-eluting stents.
Citation: Kimura T, Morimoto T, Nakagawa Y, et al. Antiplatelet therapy and stent thrombosis after sirolimus-eluting stent implantation. Circulation. 2009;119(7):987-995.
Compared with PCI, CABG Results in Lower Rates of Major Adverse Events in Severe CAD Patients
Clinical question: What is the optimal revascularization strategy for previously untreated severe coronary artery disease (CAD)?
Background: Coronary artery bypass grafting (CABG) is the treatment of choice in three-vessel and left-main CAD. However, percutaneous coronary intervention (PCI) with drug-eluting stents often is utilized despite the lack of adequately powered randomized trials.
Study design: Prospective multicenter randomized clinical trial.
Setting: 85 hospitals in Europe and the U.S.
Synopsis: 1,800 patients with an average age of 65 and previously untreated three-vessel or left-main CAD amenable to therapy with both PCI and CABG were randomized to CABG or PCI. The primary combined endpoint was a major adverse cardiac or cerebrovascular event, defined as death, stroke, MI, or repeat revascularization. PCI was associated with a significantly higher rate of major adverse cardiac or cerebrovascular events, due mostly to a higher rate of repeat revascularization (13.5% vs. 5.9%, P<0.001). At 12 months, the two groups had similar rates of death from any cause or MI, and similar rates of the combined endpoint of death from any cause, stroke, or MI; however, the rate of stroke was 1.6% higher in the CABG group.
Hospitalists should continue to favor CABG over PCI but give consideration to the risks involved with such an intervention.
Bottom line: CABG remains the revascularization choice in patients with severe CAD.
Citation: Serruys PW, Morice MC, Kappetein AP, et al. Percuta-neous coronary intervention versus coronary artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961-972.
Pre-Medicated Central Venous Catheters Reduce Risk of Catheter-Related Bloodstream Infections
Clinical question: Does pre-treating central venous catheters with anti-infective agents prevent catheter-related bloodstream infections?
Background: Use of central venous catheters (CVC) is associated with catheter-related bloodstream infection (CRBSI), with CRBSI-related mortality rates as high as 25%. Previous reviews have indicated that CVCs coated or impregnated with anti-infectives may reduce CRBSI incidence. This review integrates new trial data with information from prior reviews.