Very late stent thrombosis after primary percutaneous coronary intervention with bare-metal and drug-eluting stents for ST-segment elevation myocardial infarction: a 15-year single-center experience

Abstract

Objectives: The purpose of this study was to assess the frequency of very late stent thrombosis (VLST) after stenting with bare-metal stents (BMS) and drug-eluting stents (DES) for ST-segment elevation myocardial infarction (STEMI).

Background: Stent thrombosis occurs more frequently after stenting for STEMI than after elective stenting, but there are little data regarding VLST.

Methods: Consecutive patients (n = 1,463) who underwent stenting for STEMI were prospectively enrolled in our database. BMS were implanted exclusively from 1995 to 2002, and DES and BMS were implanted from 2003 to 2009. Follow-up was obtained at 1 to 15 years.

Results: BMS patients (n = 1,095) were older and had more shock, whereas DES patients (n = 368) had more diabetes and smaller vessels. Stent thrombosis occurred in 107 patients, of which 42 were VLST (>1 year). Stent thrombosis continued to increase to at least 11 years with BMS and to at least 4.5 years with DES. Stent thrombosis rates with BMS versus DES were similar at 1 year (5.1% and 4.0%, respectively) but increased more with DES after the first year (1.9%/year vs. 0.6%/year, respectively). Landmark analysis (>1 year) found DES had a higher frequency of VLST (p < 0.001) and reinfarction (p = 0.003). DES was the only significant independent predictor of VLST (hazard ratio: 3.79, 95% confidence interval: 1.64 to 8.79, p = 0.002).

Conclusions: VLST after primary PCI for STEMI occurs with relatively high frequency to at least 11 years with BMS and to at least 4.5 years with DES. Very late stent thrombosis and reinfarction (>1 year) were more frequent with DES. New strategies are needed to manage this problem.

Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1. Kaplan-Meier Estimates of ST Rates After Primary PCI With BMS and DES for STEMI

This figure compares cumulative stent thrombosis (ST) rates (Academic Research Consortium definite or probable) for bare-metal stents (BMS) and drug-eluting stents (DES) used with primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction. The BMS were implanted exclusively from 1995 to 2002, whereas BMS and DES were implanted from 2003 to 2009.

Figure 2. Landmark Analysis Showing Kaplan-Meier Estimates of VLST and Reinfarction After Primary PCI With DES and BMS for STEMI

(A) Landmark analysis of the cumulative frequency of very late stent thrombosis (VLST) (>1 year) comparing BMS and DES. (B) Landmark analysis of the cumulative frequency of reinfarction (>1 year) comparing BMS and DES. BMS were implanted exclusively from 1995 to 2002, whereas both stents were implanted from 2003 to 2009. Other abbreviations as in Figure 1.

Figure 3. Kaplan-Meier Estimates of Mortality and Reinfarction Rates After Primary PCI With DES and BMS for STEMI

(A) Cumulative cardiac mortality rates after primary PCI for STEMI comparing BMS and DES. (B) Cumulative reinfarction rates after primary PCI for STEMI comparing BMS and DES. BMS were implanted exclusively from 1995 to 2002, whereas both stents were implanted from 2003 to 2009. Abbreviations as in Figure 1.

Figure 4. Kaplan-Meier Estimates of Cumulative ST Rates After Primary PCI With DES and BMS for STEMI in the DES Era

(A) Cumulative frequency of ST (Academic Research Consortium definite or probable) comparing BMS and DES. (B) Landmark analysis showing the cumulative frequency of VLST (>1 year) comparing BMS and DES. Both Figures 4A and 4B show data from the DES era only (2003 to 2009) when both BMS and DES were available for implantation. Abbreviations as in Figure 1.