Personalised antiplatelet therapy in stent thrombosis: observations from the Clopidogrel Resistance in Stent Thrombosis (CREST) registry

• Published in: Heart (British Cardiac Society) Vol. 98; no. 9; pp. 706 - 711
• Main Authors: Sambu, Nalyaka, Radhakrishnan, Ashwin, Dent, Hazel, Calver, Alison Louise, Corbett, Simon, Gray, Huon, Simpson, Iain A, Curzen, Nick
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and British Cardiovascular Society 01.05.2012; BMJ Publishing Group; BMJ Publishing Group LTD
• Subjects: Acute coronary syndromes; Aged; Aspirin; Aspirin - administration & dosage; Aspirin - therapeutic use; Biological and medical sciences; Blood platelets; Cardiology. Vascular system; Coronary Thrombosis - blood; Coronary Thrombosis - drug therapy; Coronary Thrombosis - epidemiology; Dose-Response Relationship, Drug; Drug Resistance; Electrocardiography; Female; Follow-Up Studies; Graft Occlusion, Vascular - blood; Graft Occlusion, Vascular - drug therapy; Graft Occlusion, Vascular - epidemiology; Humans; Laboratories; Male; Medical sciences; Patients; Platelet Aggregation - drug effects; Platelet Aggregation Inhibitors - administration & dosage; Platelet Aggregation Inhibitors - therapeutic use; Prevalence; Prospective Studies; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects); Registries; Thrombelastography; Thrombosis; Ticlopidine - administration & dosage; Ticlopidine - analogs & derivatives; Ticlopidine - therapeutic use; Treatment Outcome; United Kingdom - epidemiology; Endoprosthesis; Instrumentation therapy; Cardiovascular disease; Stent; Thrombosis; Antiplatelet agent; Vascular disease; Resistance; Chemotherapy; Crest; Treatment; Observation; Clopidogrel; Circulatory system; Cardiology
• ISSN: 1355-6037; 1468-201X; 1468-201X
• DOI: 10.1136/heartjnl-2011-301164

ObjectivePrevious studies have demonstrated significant heterogeneity in responses to antiplatelet therapy (APT), and high residual platelet reactivity is associated with the risk of ischaemic events, including stent thrombosis (ST). The prevalence of APT hyporesponsiveness in a ‘real world’ registry of ST patients and the feasibility of personalising APT are reported.Patients and setting39 consecutive patients admitted to a single regional cardiothoracic centre with definite ST were prospectively evaluated.InterventionsResponse to aspirin and clopidogrel was measured following discharge using short thrombelastography (TEG), a rapid, well validated near patient platelet function test. Treatment modification in hyporesponders comprised an increase in aspirin dose and/or changing clopidogrel to prasugrel or ticagrelor. Short TEG was repeated following treatment modification to ensure an adequate response had been achieved.Results12 (31%) patients had an adequate response to both aspirin and clopidogrel, 16 (41%) were hyporesponsive to clopidogrel alone, one (3%) was hyporesponsive to aspirin alone and 10 (26%) were hyporesponsive to both aspirin and clopidogrel. Following treatment modification, an adequate response to aspirin and P2Y12 agent was achieved in 10 (91%) and 22 (85%) patients, respectively. None has presented with a further ST episode.ConclusionsThere is a high prevalence of hyporesponsiveness to APT in patients with ST. Improved APT efficacy can be achieved by tailored therapy. Short TEG is a plausible platelet function test that can be used to deliver point of care personalised APT.