Coronary artery stent thrombosis: Incidence and risk factors
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- J Dawn Abbott, MD, FACC
J Dawn Abbott, MD, FACC
- Associate Professor of Medicine
- Brown Medical School
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- Stephan Windecker, MD
Stephan Windecker, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Department of Cardiology
- Bern University Hospital
Coronary artery stents are used in the majority of patients who undergo percutaneous coronary intervention (PCI), as they significantly reduce the need for repeat target vessel revascularization compared to balloon angioplasty. (See "Intracoronary stent restenosis", section on 'Incidence of restenosis'.)
Stent thrombosis is an uncommon but serious complication that almost always presents as death or a large non-fatal myocardial infarction (MI), usually with ST elevation. It is estimated that less than 10 percent of cardiac deaths after stent placement are attributable to stent thrombosis, with most of the remainder being due to disease progression . This issue is discussed in detail separately. (See "Drug-eluting compared to bare metal intracoronary stents", section on 'DES compared to BMS'.)
Stent thrombosis can occur acutely (within 24 hours), subacutely (within 30 days), or as late as one year (late) or more (very late) after stent placement. Stent thrombosis within the first year appears to occur with similar frequency in patients with bare metal stents (BMS) or drug-eluting stents (DES), as long as patients are treated with dual antiplatelet therapy (aspirin plus a platelet P2Y12 receptor blocker) for the recommended duration. The period of risk requiring dual antiplatelet therapy (DAPT) is longer with DES, due at least in part to delayed neointimal coverage. (See 'Very late stent thrombosis' below.)
General issues related to stent thrombosis will be reviewed in this topic. The prevention and management of stent thrombosis are discussed separately. (See "Antiplatelet therapy after coronary artery stenting" and "Coronary artery stent thrombosis: Clinical presentation and management".)
The randomized clinical trials that have evaluated the frequency of coronary artery stent thrombosis have not used a uniform definition in their protocols, leading to difficulty in comparing the different studies. The following definitions were used in most studies and, for the purpose of this discussion, will be called the protocol definition :
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- INTRAPROCEDURAL STENT THROMBOSIS
- TIMING AND INCIDENCE
- Bare metal stents
- Drug-eluting stents
- Impact of ACS
- RISK FACTORS
- Early and late stent thrombosis
- Very late stent thrombosis
- Other issues related to risk
- - On-label versus off-label use
- - Nonanatomic factors
- - Incomplete stent apposition
- COMPARISON OF DES AND BMS
- Late and one-year cumulative stent thrombosis
- Very late and cumulative long-term stent thrombosis
- COMPARISON OF DIFFERING DES
- Late and cumulative one-year stent thrombosis
- Very late stent and cumulative two-year thrombosis