Letter by Lozano et al Regarding Article, “Increased Risk of Bleeding in Patients on Clopidogrel Therapy After Drug-Eluting Stents Implantation: Insights From the HMO Research Network–Stent Registry (HMORN-Stent)”

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HomeCirculation: Cardiovascular InterventionsVol. 3, No. 5Letter by Lozano et al Regarding Article, “Increased Risk of Bleeding in Patients on Clopidogrel Therapy After Drug-Eluting Stents Implantation: Insights From the HMO Research Network–Stent Registry (HMORN-Stent)” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Lozano et al Regarding Article, “Increased Risk of Bleeding in Patients on Clopidogrel Therapy After Drug-Eluting Stents Implantation: Insights From the HMO Research Network–Stent Registry (HMORN-Stent)” Iñigo Lozano, Oliva C. Fernández-Cimadevilla and Vicente Barriales Iñigo LozanoIñigo Lozano Hospital Central AsturiasOviedo, Spain (Lozano, Fernández-Cimadevilla, Barriales) Search for more papers by this author , Oliva C. Fernández-CimadevillaOliva C. Fernández-Cimadevilla Hospital Central AsturiasOviedo, Spain (Lozano, Fernández-Cimadevilla, Barriales) Search for more papers by this author and Vicente BarrialesVicente Barriales Hospital Central AsturiasOviedo, Spain (Lozano, Fernández-Cimadevilla, Barriales) Search for more papers by this author Originally published1 Oct 2010https://doi.org/10.1161/CIRCINTERVENTIONS.110.958355Circulation: Cardiovascular Interventions. 2010;3:e24To the Editor:We read with interest the article by Tsai et al1 regarding the risk of bleeding with clopidogrel after drug-eluting stents (DES). The authors observed an increase in bleeding events with clopidogrel but also a reduction in myocardial infarction and death rate in some of the studied periods and pose the question about the optimal duration of double antiplatelet therapy after DES. Since the substitution of ticlopidine by clopidogrel in 1997 added to aspirin in the first month after placement of bare metal stents, we have assisted its progressive use with different and longer indications in various subsets of patients with coronary disease. Concretely, the current guidelines recommend double antiplatelet therapy for the first 12 months after DES but also during the first 9 to 12 months after any acute coronary syndrome, with or without ST-elevation. We believe that the benefits of clopidogrel must be counterbalanced with the risk of bleeding; however, not all the mentioned indications provide the same benefit, and DES represent the most important indication of clopidogrel. Although in acute coronary syndromes and despite the high number of patients included in the studies, no differences in terms of mortality with or without clopidogrel were found,2 the scenario after DES is completely different. The first cause of stent thrombosis is premature cessation of the antiplatelet therapy, and, unfortunately, we have learned the fatal consequences of the event.3 We believe that clopidogrel added to aspirin should be maintained after DES for the first 12 months despite the increase in bleeding events. In a cohort of 382 patients followed once every 3 months during the first year after DES in our center, 49 (12.8%) discontinued prematurely the double therapy and, as occurred in the Tsai series, we observed an increase in mortality during the second semester related to premature discontinuation. This fact was strongly associated with cardiac mortality or nonfatal stent thrombosis (odds ratio, 7.03; 95% confidence interval, 2.03 to 24.7; P=0.002) and all-caused mortality or stent thrombosis (odds ratio, 11.7; 95% confidence interval, 3.42 to 40.48; P<0.000). Eight patients of the 49 who discontinued the therapy died or had stent thrombosis. Despite that all but 1 discontinued it in the first semester, the event occurred in the second semester in 5 of the 7 patients. Seven of the 49 discontinued the therapy because of bleeding events, but none of them died secondary to it.4 Although these results are clearly in disagreement with other authors who defend a duration of only 6 months,5 given the results of the Tsai series and ours, we strongly believe that is necessary to extend the recommendation up to 12 months, even at the price of an increase in bleeding events.Iñigo Lozano, MD, PhD, FACC, FESCOliva C. Fernández-Cimadevilla, MDVicente Barriales, MD, PhD, FESC Hospital Central Asturias Oviedo, SpainDisclosuresNone.