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| {{SI}}
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| {{WikiDoc Cardiology Network Infobox}}
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| {{CMG}}
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| '''Associate Editors-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
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| {{Editor Help}}
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| ==Overview==
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| The main principle of the preventive treatment for stent thrombosis is to perform the best [[PCI]] possible, including good expansion and apposition of the stent. In this context, the role of '''intravascular ultrasound''' has been studied extensively and can be helpful<ref name="pmid18550555">{{cite journal |author=Roy P, Steinberg DH, Sushinsky SJ, ''et al.'' |title=The potential clinical utility of intravascular ultrasound guidance in patients undergoing percutaneous coronary intervention with drug-eluting stents |journal=Eur. Heart J. |volume=29 |issue=15 |pages=1851–7 |year=2008 |month=August |pmid=18550555 |doi=10.1093/eurheartj/ehn249 |url=}}</ref><ref name="pmid18360858">{{cite journal |author=Gerber R, Colombo A |title=Does IVUS guidance of coronary interventions affect outcome? a prime example of the failure of randomized clinical trials |journal=Catheter Cardiovasc Interv |volume=71 |issue=5 |pages=646–54 |year=2008 |month=April |pmid=18360858 |doi=10.1002/ccd.21489 |url=}}</ref>.
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| Combined [[antiplatelet]] therapy for the preventive treatment has been extensively studied and are routinely recommended.
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| *There are better outcomes noted with the use of [[aspirin]] plus [[ticlopidine]] or [[clopidogrel]] than with aspirin plus [[warfarin]] or aspirin alone<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref><ref name="pmid8598866">{{cite journal| author=Schömig A, Neumann FJ, Kastrati A, Schühlen H, Blasini R, Hadamitzky M et al.| title=A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 17 | pages= 1084-9 | pmid=8598866 | doi=10.1056/NEJM199604253341702 | pmc= | url= }} </ref><ref name="pmid9778323">{{cite journal| author=Bertrand ME, Legrand V, Boland J, Fleck E, Bonnier J, Emmanuelson H et al.| title=Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study. | journal=Circulation | year= 1998 | volume= 98 | issue= 16 | pages= 1597-603 | pmid=9778323 | doi= | pmc= | url= }} </ref><ref name="pmid9815866">{{cite journal| author=Urban P, Macaya C, Rupprecht HJ, Kiemeneij F, Emanuelsson H, Fontanelli A et al.| title=Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS). | journal=Circulation | year= 1998 | volume= 98 | issue= 20 | pages= 2126-32 | pmid=9815866 | doi= | pmc= | url= }} </ref><ref name="pmid10931801">{{cite journal| author=Bertrand ME, Rupprecht HJ, Urban P, Gershlick AH, CLASSICS Investigators| title=Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting : the clopidogrel aspirin stent international cooperative study (CLASSICS). | journal=Circulation | year= 2000 | volume= 102 | issue= 6 | pages= 624-9 | pmid=10931801 | doi= | pmc= | url= }} </ref>.
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| *Preliminary evidence suggests [[prasugrel]] resulted in fewer ischaemic outcomes including stent thrombosis than with standard [[clopidogrel]]<ref name="pmid18377975">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP et al.| title=Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1353-63 | pmid=18377975 | doi=10.1016/S0140-6736(08)60422-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18377975 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783188 Review in: ACP J Club. 2008 Sep 16;149(3):12] </ref>.
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| ==Clinical trial data==
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| *In '''STARS trial'''<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK et al.| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url= }} </ref>, studying 1653 patients showed superiority of [[aspirin]] and [[ticlopidine]] over combination of aspirin and [[warfarin]] or aspirin alone for reducing subacute stent thrombosis, although there were more hemorrhagic complications than with aspirin alone.
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| *A similar benefit for combined [[aspirin]] plus [[ticlopidine]] was noted in another randomized controlled trial<ref name="pmid8598866">{{cite journal| author=Schömig A, Neumann FJ, Kastrati A, Schühlen H, Blasini R, Hadamitzky M et al.| title=A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 17 | pages= 1084-9 | pmid=8598866 | doi=10.1056/NEJM199604253341702 | pmc= | url= }} </ref>.
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| *Results from double blinded randomized studies- '''PCI-CURE''' trial<ref name="pmid11520521">{{cite journal| author=Mehta SR, Yusuf S, Peters RJ, Bertrand ME, Lewis BS, Natarajan MK et al.| title=Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. | journal=Lancet | year= 2001 | volume= 358 | issue= 9281 | pages= 527-33 | pmid=11520521 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11520521 }} </ref>, analyzing 2658 patients and '''CREDO''' trial<ref name="pmid12435254">{{cite journal| author=Steinhubl SR, Berger PB, Mann JT, Fry ET, DeLago A, Wilmer C et al.| title=Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 288 | issue= 19 | pages= 2411-20 | pmid=12435254 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12435254 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12841706 Review in: ACP J Club. 2003 Jul-Aug;139(1):2] </ref>, analyzing 2116 patients, revealed the benefit of [[clopidogrel]] therapy increased with time and provide evidence for at least one year therapy in patients with [[BMS]]. However both the studies did not evaluate [[DES]].
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| *'''TRITON TIMI-38'''<ref name="pmid18377975">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP et al.| title=Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. | journal=Lancet | year= 2008 | volume= 371 | issue= 9621 | pages= 1353-63 | pmid=18377975 | doi=10.1016/S0140-6736(08)60422-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18377975 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18783188 Review in: ACP J Club. 2008 Sep 16;149(3):12] </ref>trial analyzing 12,844 patients who underwent stenting for [[ACS]] revealed intensive antiplatelet therapy with [[prasugrel]] resulted in fewer ischaemic outcomes including stent thrombosis than with standard [[clopidogrel]].These findings were statistically robust irrespective of stent type, and the data affirm the importance of intensive platelet inhibition in patients with [[intracoronary stents]].
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| ==Guidelines for Prevention==
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| The 2008 American College of Chest Physician illustrates the following guidelines for primary and secondary prevention of coronary artery disease<ref name="pmid18574278">{{cite journal| author=Becker RC, Meade TW, Berger PB, Ezekowitz M, O'Connor CM, Vorchheimer DA et al.| title=The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 776S-814S | pmid=18574278 | doi=10.1378/chest.08-0685 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574278 }} </ref>.
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| {{cquote|
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| '''1.''' For patients after [[myocardial infarction]], after [[ACS]], and those with stable [[CAD]] and patients
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| after percutaneous coronary intervention ([[PCI]]) with stent placed, we recommend daily [[aspirin]] (75–100 mg) as indefinite therapy. (Grade 1A).
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| '''2.''' For patients who undergo [[bare metal stent]] placement, we recommend the combination of [[aspirin]] and [[clopidogrel]] for at least 4 weeks (Grade 1A).
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| '''3.''' For patients undergoing [[PCI]] with [[BMS]] placement following [[ACS]], we recommend 12 months of [[aspirin]] (75–100 mg/d) plus [[clopidogrel]] (75 mg/d) over [[aspirin]] alone (Grade 1A).
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| '''4.''' For patients undergoing [[PCI]] with a [[DES]], we recommend [[aspirin]] (75–100 mg/d) plus [[clopidogrel]] (75 mg/d for at least 12 months) [Grade 1A for 3 to 4 months; Grade 1B for 4 to 12 months]. Beyond 1 year, we suggest continued treatment with [[aspirin]] plus [[clopidogrel]] indefinitely if no bleeding or other tolerability issues (Grade 2C).}}
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