Transcript Prevalence, Predictors, and Long-Term Prognosis of Premature Discontinuation of Oral Antiplatelet Therapy After Drug Eluting Stent Implantation Roberta Rossini, MD, PhD, Davide.

Prevalence, Predictors, and Long-Term Prognosis of Premature Discontinuation of
Oral Antiplatelet Therapy After Drug Eluting Stent Implantation
Roberta Rossini, MD, PhD, Davide Capodanno, MD, Corrado Lettieri, MD, Giuseppe Musumeci, MD, Tamar Nijaradze, MD,
Michele Romano, MD, Nikoloz Lortkipanidze, MD, Nicola Cicorella, MD, Giuseppe Biondi Zoccai, MD, Vasile Sirbu, MD,
Antonio Izzo, MD, Giulio Guagliumi, MD, Orazio Valsecchi, MD, Antonello Gavazzi, MD and Dominick J. Angiolillo, MD, PhD
USC Cardiologia, Dipartimento Cardiovascolare, Ospedali Riuniti di Bergamo, Italy
Divisione di Cardiologia, Ospedale Carlo Poma, Mantova, Italy
Divisione di Cardiologia, Università di Torino, Italy
University of Florida College of Medicine- Jacksonville, Florida, US
American Journal of Cardiology
Volume 107, Issue 2, Pages 186-194 (January 2011)
DOI: 10.1016/j.amjcard.2010.08.067
Copyright © 2011 Elsevier Inc. Terms and Conditions
Aim of the Study
The aims of the present study were to determine
the prevalence and predictors of premature
discontinuation of long-term oral antiplatelet
therapy after DES implantation and to evaluate its
effects on prognosis in relation to the time and
duration of the discontinuation
Methods
 We studied 1358 consecutive pts treated with DES and discharged on dual
antiplatelet therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day)
 Clopidogrel was maintained for 12 months
 Pts were followed-up for 32.4±11.3 months
 Prevalence and predictors of aspirin and/or clopidogrel discontinuation
were assessed
 Major adverse cardiac events (MACE), defined as death, acute coronary
syndrome leading to hospitalization, and stroke, were recorded.
Probable/possible/definite stent thrombosis were also recorded
Results
8.8% of patients discontinued one or both antiplatelet agents within the first 12 months
(early discontinuation) and 4.8% withdrew aspirin after 1 year (late discontinuation)
8,8%
Discontinuation Causes:
4,8%
86,4%
 Surgery 34.5%
 Bleeding 21%
 Medical decision 17.6%
 Dental interventions 7.6%
 Economic/burocratic reasons 5.9%
 Anticoagulant therapy 5.0%
No discontinuation
Early discontinuation
Late discontinuation
Rossini R et al. Am J Card 2011, 107: 186-194
Predictors of Discontinuation
Early Discontinuation
 in-hospital major bleeding (OR=9.00, p<0.001)
 statins at discharge (OR=0.36, p<0.001)
oral anticoagulants at discharge (OR=8.21, p<0.001)
Late Discontinuation
 history of prior stroke (OR=5.21, p<0.001)
Rossini R et al. Am J Card 2011, 107: 186-194
Discontinuation and Prognosis
Patients who discontinued antiplatelet therapy had a higher incidence of death, MACE and stent
thrombosis
%
MACE
Rossini R et al. Am J Card 2011, 107: 186-194
Overall death and discontinuation
100
Survival (%)
90
Late discontinuation
80
No discontinuation
70
Early discontinuation
Log rank test
60 Overall: p=0.001
No discontinuation vs early discontinuation: p=0.001
50 No discontinuation vs late discontinuation: p=0.223
Early discontinuation vs late discontinuation: p=0.011
No discontinuation vs early+late discontinuation: p=0.018
40
12
24
36
48
Months
Rossini R et al. Am J Card 2011, 107: 186-194
MACE and discontinuation
Late discontinuation
100
Survival free from MACE (%)
No discontinuation
Early discontinuation
90
80
70
60 Log rank test
Overall: p=0.001
No discontinuation vs early discontinuation: p=0.001
50 No discontinuation vs late discontinuation: p=0.223
Early discontinuation vs late discontinuation: p=0.011
No discontinuation vs early+late discontinuation: p=0.018
40
24
36
12
48
Months
Rossini R et al. Am J Card 2011, 107: 186-194
Survival free from Stent Thrombosis (%)
Stent Thrombosis and discontinuation
Late discontinuation
100
No discontinuation
90
Early discontinuation
80
70
Log rank test
Overall: p=0.031
No discontinuation vs early discontinuation: p=0.015
No discontinuation vs late discontinuation: p=0.175
Early discontinuation vs late discontinuation: p=0.653
No discontinuation vs early+late discontinuation: p=0.009
60
50
40
0
12
24
36
48
Months
Rossini R et al. Am J Card 2011, 107: 186-194
Death, MACE or stent thrombosis and time of discontinuation
P for trend = 0.004
P=0.008
%
P=0.02
P for trend = 0.004
P=0.008
P=0.02
P=0.10
P=0.10
P for trend = 0.004
P=0.008
P=0.02
P=0.10
Rossini R et al. Am J Card 2011, 107: 186-194
Association between thienopyridine and/or aspirin discontinuation and
MACE stratified by time intervals
No Discontinuation
Discuntinuation of Aspirin Only
Discuntinuation of Thienopyridines Only
Discuntinuation of Both
%
P = 0.07
P=0.11
P=1.00
P=0.001
P=0.002
P=0.08
P = 0.24
P=0.001
P=0.26
P = 0.20
P=0.88
P=1.0
Rossini R et al. Am J Card 2011, 107: 186-194
Conclusions
• Premature discontinuation of antiplatelet therapy is relatively
common, especially within the first year, and strongly associated with
increased cardiovascular events, including ST and death.
• Early discontinuation of antiplatelet agents within the first year was
predicted by in-hospital major bleeding, oral anticoagulant use at
discharge, and the lack of statin prescription.
• Strategies to improve compliance to antiplatelet therapy in patients
with greater likelihood to interrupt treatment are warranted