Incidence and predictors of outcomes after a first definite coronary stent thrombosis

Aims: Stent thrombosis (ST) is a rare but potentially fatal complication of coronary artery stenting. Little is known about the optimal treatment strategy at the time of an ST event. We aimed to identify the incidence and predictors of adverse cardiac events after treatment of a definite ST.

Methods and results: A total of 695 patients with definite ST were included between 1996 and 2017 in two academic medical centres. The primary endpoint was MACE, the composite of cardiac death, myocardial infarction (MI) and target vessel revascularisation (TVR). Mean age was 62.8±12.1 years and 76.3% were male. ST occurred at a median of 22 days (IQR 3-551 days); 50.8% were early and 49.2% were late/very late ST. At 60-month follow-up, the MACE rate was 43.7%, cardiac death 19.5%, MI 17.9%, TVR 24.8%, and repeat definite ST was 12.1% (10.5% in target vessel). Independent predictors of MACE were cardiogenic shock (HR 2.54, 95% CI: 1.75-3.70; p<0.001), ST in the LAD (HR 1.76, 95% CI: 1.32-2.35; p<0.001), prior CVA/TIA (HR 1.68, 95% CI: 1.08-2.62; p=0.020), peripheral vascular disease (HR 1.55, 95% CI: 1.00-2.39; p=0.046), multivessel disease (HR 1.53, 95% CI: 1.12-2.08; p=0.007), and final TIMI flow 2-3 (HR 0.54, 95% CI: 0.34-0.85; p=0.009). No specific treatment of ST influenced MACE; however, new-generation P2Y12 inhibitors reduced the risk of MI (HR 0.56, 95% CI: 0.32-0.99; p=0.049).

Conclusions: The incidence of adverse events remains high after a first episode of ST. New-generation P2Y12 inhibitors reduce the risk of MI. Additional stenting, GP IIb/IIIa inhibitors and thrombectomy did not improve outcomes following ST.